Provider Demographics
NPI:1104140607
Name:FAGUNDES, LAURA (PA-C)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:FAGUNDES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:FAGUNDES
Other - Last Name:KLEIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1100 FEDERAL BLVD.
Mailing Address - Street 2:WESTSIDE PEDIATRIC CLINIC
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80204
Mailing Address - Country:US
Mailing Address - Phone:303-436-4200
Mailing Address - Fax:303-436-4409
Practice Address - Street 1:3825 N LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80205-3316
Practice Address - Country:US
Practice Address - Phone:303-500-1518
Practice Address - Fax:720-598-0440
Is Sole Proprietor?:No
Enumeration Date:2010-03-26
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2977363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO30128765Medicaid