Provider Demographics
NPI:1104312339
Name:KUSHNER, LAURA ELIZABETH (PA-C)
Entity type:Individual
Prefix:MS
First Name:LAURA
Middle Name:ELIZABETH
Last Name:KUSHNER
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 1:3245 E US HIGHWAY 50
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-9342
Mailing Address - Country:US
Mailing Address - Phone:719-285-2888
Mailing Address - Fax:
Practice Address - Street 1:3245 E US HIGHWAY 50
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-9342
Practice Address - Country:US
Practice Address - Phone:719-285-2888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-11
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1150230363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant