Provider Demographics
NPI:1396282190
Name:DUCLOS, LAISNER (NP)
Entity type:Individual
Prefix:
First Name:LAISNER
Middle Name:
Last Name:DUCLOS
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13750 LEMOLI AVE APT 68
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-7767
Mailing Address - Country:US
Mailing Address - Phone:954-274-4611
Mailing Address - Fax:
Practice Address - Street 1:38600 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93551-4483
Practice Address - Country:US
Practice Address - Phone:661-382-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-31
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95005924363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner