Provider Demographics
NPI:1336267012
Name:MOTTL, LAURIE JENNIFER (PA-C)
Entity Type:Individual
Prefix:MS
First Name:LAURIE
Middle Name:JENNIFER
Last Name:MOTTL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LAURIE
Other - Middle Name:J
Other - Last Name:BAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4401 N INTERSTATE 35 UNIT 312
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76207-3318
Mailing Address - Country:US
Mailing Address - Phone:940-381-1501
Mailing Address - Fax:940-591-7830
Practice Address - Street 1:4308 MESA DR
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76207-3459
Practice Address - Country:US
Practice Address - Phone:940-381-1501
Practice Address - Fax:940-591-7830
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4351363A00000X
IL085-002366363AM0700X
TXPA07844363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ429843Medicaid