Provider Demographics
NPI:1063700854
Name:VIVIO-KARLE, LAURA L (PA-C)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:L
Last Name:VIVIO-KARLE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1721 S STEPHENSON AVE
Mailing Address - Street 2:
Mailing Address - City:IRON MOUNTAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49801-3637
Mailing Address - Country:US
Mailing Address - Phone:906-774-1313
Mailing Address - Fax:906-776-5639
Practice Address - Street 1:1721 S STEPHENSON AVE
Practice Address - Street 2:
Practice Address - City:IRON MOUNTAIN
Practice Address - State:MI
Practice Address - Zip Code:49801-3637
Practice Address - Country:US
Practice Address - Phone:906-774-1313
Practice Address - Fax:906-776-5639
Is Sole Proprietor?:No
Enumeration Date:2011-07-14
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2764-23363A00000X
MI5601006404363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5220026OtherBCBS MI
WI1063700854Medicaid
WI322500130Medicare PIN
WI1063700854Medicaid