Provider Demographics
NPI:1063759223
Name:MITCHELL, LAURAE N (PA)
Entity type:Individual
Prefix:
First Name:LAURAE
Middle Name:N
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LAURAE
Other - Middle Name:N
Other - Last Name:MARTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1536 E PRIMROSE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-7928
Mailing Address - Country:US
Mailing Address - Phone:417-882-1818
Mailing Address - Fax:
Practice Address - Street 1:1536 E PRIMROSE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-7928
Practice Address - Country:US
Practice Address - Phone:417-882-1818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1063759223Medicaid