Provider Demographics
NPI:1194155283
Name:LASER, STEPHANIE (MMS,, PA-C)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:LASER
Suffix:
Gender:F
Credentials:MMS,, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5744 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-4302
Mailing Address - Country:US
Mailing Address - Phone:312-335-0180
Mailing Address - Fax:773-275-4679
Practice Address - Street 1:5744 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60660-4302
Practice Address - Country:US
Practice Address - Phone:312-335-0180
Practice Address - Fax:773-275-4679
Is Sole Proprietor?:No
Enumeration Date:2013-11-26
Last Update Date:2013-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.004878363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant