Provider Demographics
NPI:1649632266
Name:REQUENEZ, LAURA (PA)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:REQUENEZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17766 VERDE PKWY STE 230
Mailing Address - Street 2:
Mailing Address - City:SELMA
Mailing Address - State:TX
Mailing Address - Zip Code:78154-2226
Mailing Address - Country:US
Mailing Address - Phone:201-998-2410
Mailing Address - Fax:
Practice Address - Street 1:17766 VERDE PKWY STE 230
Practice Address - Street 2:
Practice Address - City:SELMA
Practice Address - State:TX
Practice Address - Zip Code:78154-2226
Practice Address - Country:US
Practice Address - Phone:201-998-2410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-23
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA09836363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX741679824OtherGROUP TAX ID
TX742557428OtherGROUP TAX ID