Provider Demographics
NPI:1538414107
Name:DUNNE, LAURIE A (PA)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:A
Last Name:DUNNE
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 1:110 CAPCOM AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-6531
Mailing Address - Country:US
Mailing Address - Phone:919-867-0360
Mailing Address - Fax:877-920-1934
Practice Address - Street 1:110 CAPCOM AVE
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-6531
Practice Address - Country:US
Practice Address - Phone:919-867-0360
Practice Address - Fax:877-920-1934
Is Sole Proprietor?:No
Enumeration Date:2012-07-19
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NC0010-06415363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY121019000029OtherFIDELIS CARE NY
NY03491256Medicaid
NY03491256Medicaid