Provider Demographics
NPI:1912951922
Name:GILMORE, LAURA STEWART (PA)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:STEWART
Last Name:GILMORE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2420 JENKS AVE
Mailing Address - Street 2:SUITE C-1
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-4909
Mailing Address - Country:US
Mailing Address - Phone:850-233-3376
Mailing Address - Fax:850-522-8354
Practice Address - Street 1:2420 JENKS AVE
Practice Address - Street 2:SUITE C-1
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4909
Practice Address - Country:US
Practice Address - Phone:850-233-3376
Practice Address - Fax:850-522-8354
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9100649363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL307351300Medicaid
FL307351300Medicaid
FLE2195WMedicare ID - Type UnspecifiedMEDICARE INDIVIDUAL