Provider Demographics
NPI:1245553437
Name:HARTLIEB, LAURA ANN
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:ANN
Last Name:HARTLIEB
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 SHERWOOD GATE
Mailing Address - Street 2:
Mailing Address - City:OYSTER BAY
Mailing Address - State:NY
Mailing Address - Zip Code:11771-3805
Mailing Address - Country:US
Mailing Address - Phone:516-417-0229
Mailing Address - Fax:
Practice Address - Street 1:177 FORT WASHINGTON AVE
Practice Address - Street 2:7 GARDEN NORTH 435- MILSTEIN HOSPITAL BUILDING
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3733
Practice Address - Country:US
Practice Address - Phone:212-305-1743
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-02
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY23013902363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant