Provider Demographics
NPI:1215054630
Name:FOCACCI, LAURIE (PA-C, MPS)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:
Last Name:FOCACCI
Suffix:
Gender:F
Credentials:PA-C, MPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:655 LAWNTON TER
Mailing Address - Street 2:
Mailing Address - City:HOLMES
Mailing Address - State:PA
Mailing Address - Zip Code:19043-1021
Mailing Address - Country:US
Mailing Address - Phone:484-494-6349
Mailing Address - Fax:
Practice Address - Street 1:701 N CLAYTON ST
Practice Address - Street 2:MOB 401
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19805-3165
Practice Address - Country:US
Practice Address - Phone:302-421-4800
Practice Address - Fax:302-421-4189
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC5-0000525363AS0400X
PAMA052669363AS0400X
NY008557-1363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0001001202Medicaid
2120316000OtherBLUE SHIELD PC
2120316000OtherKEYSTONE
2935112OtherAETNA