Provider Demographics
NPI:1821190240
Name:KUSTABORDER, LAURA LEE (PA-C)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:LEE
Last Name:KUSTABORDER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:119 OCALA TRAIL DR
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15235-3531
Mailing Address - Country:US
Mailing Address - Phone:412-874-7129
Mailing Address - Fax:
Practice Address - Street 1:5115 CENTRE AVE
Practice Address - Street 2:HILLMAN CANCER CENTER, 2ND FLOOR
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15232-1301
Practice Address - Country:US
Practice Address - Phone:412-864-7930
Practice Address - Fax:412-623-2540
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMA054247363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA255864QJDMedicare PIN