Provider Demographics
NPI:1457434458
Name:DEAN, LAURA (PA)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:DEAN
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 1:105 CARNEGIE PL
Mailing Address - Street 2:STE 103
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-3980
Mailing Address - Country:US
Mailing Address - Phone:770-716-7999
Mailing Address - Fax:
Practice Address - Street 1:105 CARNEGIE PL
Practice Address - Street 2:STE 103
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-3980
Practice Address - Country:US
Practice Address - Phone:770-716-7999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP00964466OtherMEDICARE RAILROAD
GAP00964466OtherMEDICARE RAILROAD
GA97WCFJFMedicare ID - Type Unspecified
GAP00964466Medicare PIN