Provider Demographics
NPI:1801939137
Name:NOFAL, LAURA LEA (PAC)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:LEA
Last Name:NOFAL
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:LEA
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4205 BELFORT RD STE 4015
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-3623
Mailing Address - Country:US
Mailing Address - Phone:904-450-6063
Mailing Address - Fax:904-539-4091
Practice Address - Street 1:801 E 6TH ST STE 604
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401-3699
Practice Address - Country:US
Practice Address - Phone:850-804-3845
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105582363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL75127331Medicaid
97WCJKLMedicare PIN