Basic Information
| Provider Information | |||||||||
| NPI: | 1407883283 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GINOZA | ||||||||
| FirstName: | LAURA | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 36115 SCHOOLCRAFT RD | ||||||||
| Address2: | |||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481501216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344640887 | ||||||||
| FaxNumber: | 7344020254 | ||||||||
| Practice Location | |||||||||
| Address1: | 18263 E 10 MILE RD | ||||||||
| Address2: | SUITE D | ||||||||
| City: | ROSEVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480665805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344640887 | ||||||||
| FaxNumber: | 7344020254 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2006 | ||||||||
| LastUpdateDate: | 08/06/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA 01248 | OR | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 5601005561 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 480F37288 | 01 | MI | BLUE CROSS | OTHER |