Provider Demographics
NPI:1750983045
Name:FLAVAN, LAUREN T (PA-C)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:T
Last Name:FLAVAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 MEMORIAL DR STE 230
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-6704
Mailing Address - Country:US
Mailing Address - Phone:618-463-7874
Mailing Address - Fax:
Practice Address - Street 1:4 MEMORIAL DR STE 230
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-6704
Practice Address - Country:US
Practice Address - Phone:618-463-7874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-11
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-007804363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant