Provider Demographics
NPI:1396080800
Name:PROVENZANO, LAURA (PA-C)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:PROVENZANO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1563 ONYX DR UNIT 205
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22102-3945
Mailing Address - Country:US
Mailing Address - Phone:703-585-5951
Mailing Address - Fax:
Practice Address - Street 1:3117 DUKE ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-4518
Practice Address - Country:US
Practice Address - Phone:703-751-8800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-10
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110004424363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0110004424OtherSTATE LICENSE