Provider Demographics
NPI:1679275127
Name:LAURIA, MYCHAELA
Entity type:Individual
Prefix:
First Name:MYCHAELA
Middle Name:
Last Name:LAURIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 WEST AVE STE 125
Mailing Address - Street 2:
Mailing Address - City:SARATOGA SPRINGS
Mailing Address - State:NY
Mailing Address - Zip Code:12866-6063
Mailing Address - Country:US
Mailing Address - Phone:716-863-8317
Mailing Address - Fax:
Practice Address - Street 1:1 WEST AVE STE 125
Practice Address - Street 2:
Practice Address - City:SARATOGA SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:12866-6063
Practice Address - Country:US
Practice Address - Phone:757-953-0669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-20
Last Update Date:2025-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY331618-012083P0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program