Provider Demographics
NPI:1316010895
Name:ADDIS, LAURA D (DO)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:D
Last Name:ADDIS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:390 W LAKE MEAD PKWY STE 120
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89015-7417
Mailing Address - Country:US
Mailing Address - Phone:725-220-8477
Mailing Address - Fax:833-749-0360
Practice Address - Street 1:390 W LAKE MEAD PKWY STE 120
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89015-7417
Practice Address - Country:US
Practice Address - Phone:725-220-8477
Practice Address - Fax:833-749-0360
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1216207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1316010895Medicaid
NVPENDINGOtherMEDICARE
NV1316010895Medicaid
NVI32215Medicare UPIN