Provider Demographics
NPI:1336179423
Name:REIFSTECK, LAURA COLLEEN (PAC)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:COLLEEN
Last Name:REIFSTECK
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6201 GREENLEIGH AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLE RIVER
Mailing Address - State:MD
Mailing Address - Zip Code:21220-2004
Mailing Address - Country:US
Mailing Address - Phone:410-933-2704
Mailing Address - Fax:
Practice Address - Street 1:2021 K ST NW STE 600
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20006-1051
Practice Address - Country:US
Practice Address - Phone:202-888-8365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIAMD203363A00000X
DCPA200001625363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI54862001Medicaid
DCPA200001625OtherSTATE LICENSE
HIH56694Medicare PIN
HI54862001Medicaid