Provider Demographics
NPI:1649904251
Name:SOUTH, LAUREN MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:MARIE
Last Name:SOUTH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:MARIE
Other - Last Name:MAITNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 14890
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12212-4890
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4 CONGRESS PL
Practice Address - Street 2:
Practice Address - City:SARATOGA SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:12866-4180
Practice Address - Country:US
Practice Address - Phone:518-450-4594
Practice Address - Fax:518-450-4544
Is Sole Proprietor?:No
Enumeration Date:2022-07-11
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028489363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant