Basic Information
| Provider Information | |||||||||
| NPI: | 1447426796 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DELLORUSSO | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APN, C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CHEN | ||||||||
| OtherFirstName: | LAURA | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | APN, C | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 416457 | ||||||||
| Address2: | PRACTICE ASSOCIATES MEDICAL GROUP | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022410647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9086566280 | ||||||||
| FaxNumber: | 9732907495 | ||||||||
| Practice Location | |||||||||
| Address1: | 211 MOUNTAIN AVE | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070812221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9734670005 | ||||||||
| FaxNumber: | 9739128989 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2008 | ||||||||
| LastUpdateDate: | 11/13/2013 | ||||||||
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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 | 363LA2100X | 26NJ00079100 | NJ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | 0270865 | 05 | NJ | MEDICAID |