Provider Demographics
NPI:1205948197
Name:CANARY, LAUREN MARIE (PA)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:MARIE
Last Name:CANARY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:MARIE
Other - Last Name:ENGLISH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:515 CARLTON STREET
Mailing Address - Street 2:
Mailing Address - City:WAUCHULA
Mailing Address - State:FL
Mailing Address - Zip Code:33873
Mailing Address - Country:US
Mailing Address - Phone:863-773-6606
Mailing Address - Fax:863-773-9542
Practice Address - Street 1:515 CARLTON STREET
Practice Address - Street 2:PIONEER MEDICAL CENTER
Practice Address - City:WAUCHULA
Practice Address - State:FL
Practice Address - Zip Code:33873
Practice Address - Country:US
Practice Address - Phone:863-773-6606
Practice Address - Fax:863-773-9542
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101695363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291389500Medicaid
FLPA9101695Medicaid
P63565Medicare UPIN
FL291389500Medicaid