Provider Demographics
NPI:1386970747
Name:KOON, LAURA LYNN (PAC)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:LYNN
Last Name:KOON
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3730 RIVERMIST TER
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23113-3740
Mailing Address - Country:US
Mailing Address - Phone:804-613-8309
Mailing Address - Fax:
Practice Address - Street 1:8266 ATLEE RD STE 224
Practice Address - Street 2:
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23116-1813
Practice Address - Country:US
Practice Address - Phone:804-454-7240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-20
Last Update Date:2022-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110-003378363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1699850032Medicaid
VA0110003378OtherLICENSE
P00869721OtherRR MEDICARE PIN
VA0110003378OtherLICENSE