Provider Demographics
NPI:1366767063
Name:SODERSTROM AKINMADE, LAUREN MICHELLE (PA)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:MICHELLE
Last Name:SODERSTROM AKINMADE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 418283
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-8283
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3001 S HANOVER ST
Practice Address - Street 2:SUITE 100
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21225-1233
Practice Address - Country:US
Practice Address - Phone:855-633-0363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-06
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0004205363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDC0004205OtherPHYSICIAN ASST LICENSE