Provider Demographics
NPI:1063737252
Name:BROWN, LAUREL M (PA)
Entity type:Individual
Prefix:
First Name:LAUREL
Middle Name:M
Last Name:BROWN
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 1:931 CHEVY WAY
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-4127
Mailing Address - Country:US
Mailing Address - Phone:541-690-3555
Mailing Address - Fax:541-512-1026
Practice Address - Street 1:910 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-7822
Practice Address - Country:US
Practice Address - Phone:541-618-1380
Practice Address - Fax:541-618-1385
Is Sole Proprietor?:No
Enumeration Date:2010-03-31
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA20827363A00000X
363AM0700X
ORPA157035363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR227698Medicaid
ORR164007Medicare PIN