Provider Demographics
NPI:1811130198
Name:JANSON, LAURIE B (P A)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:B
Last Name:JANSON
Suffix:
Gender:F
Credentials:P A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 N CENTRAL AVE STE 160
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2702
Mailing Address - Country:US
Mailing Address - Phone:970-820-5000
Mailing Address - Fax:530-623-4397
Practice Address - Street 1:2923 GINNALA DR
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538-2702
Practice Address - Country:US
Practice Address - Phone:970-820-5000
Practice Address - Fax:970-820-5061
Is Sole Proprietor?:No
Enumeration Date:2009-04-15
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17874363A00000X
CO4012363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant