Basic Information
| Provider Information | |||||||||
| NPI: | 1467622159 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VICTOR | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | RPAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 222 ROCKAWAY TPKE | ||||||||
| Address2: | |||||||||
| City: | CEDARHURST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115161833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5162391800 | ||||||||
| FaxNumber: | 5162395553 | ||||||||
| Practice Location | |||||||||
| Address1: | 222 ROCKAWAY TPKE | ||||||||
| Address2: | |||||||||
| City: | CEDARHURST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115161833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5162391800 | ||||||||
| FaxNumber: | 5162395553 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2008 | ||||||||
| LastUpdateDate: | 11/12/2010 | ||||||||
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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 | 12347 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.