Provider Demographics
NPI:1063781144
Name:GERRALD, LAURA CAITLIN (PA)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:CAITLIN
Last Name:GERRALD
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 1:1208 HICKORY BLVD SW STE 102
Mailing Address - Street 2:
Mailing Address - City:LENOIR
Mailing Address - State:NC
Mailing Address - Zip Code:28645-6461
Mailing Address - Country:US
Mailing Address - Phone:828-991-4660
Mailing Address - Fax:828-991-4659
Practice Address - Street 1:1208 HICKORY BLVD SW STE 102
Practice Address - Street 2:
Practice Address - City:LENOIR
Practice Address - State:NC
Practice Address - Zip Code:28645
Practice Address - Country:US
Practice Address - Phone:828-991-4660
Practice Address - Fax:828-991-4659
Is Sole Proprietor?:No
Enumeration Date:2011-12-20
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-11611363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCRHC211OtherRHC MEDICAID (INDIANLAND)
SC428960OtherRHC MEDICARE (LANCASTER)
SCGP0641Medicaid
SCRHC127OtherRHC MEDICAID (LANCASTER)
SC423876OtherRHC MEDICARE (INDIANLAND)
SC4754Medicare PIN