Provider Demographics
NPI:1598573354
Name:BRAVO, LAURA
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:BRAVO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3909 LAPALCO BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:HARVEY
Mailing Address - State:LA
Mailing Address - Zip Code:70058-2377
Mailing Address - Country:US
Mailing Address - Phone:504-349-6900
Mailing Address - Fax:
Practice Address - Street 1:3909 LAPALCO BLVD STE 100
Practice Address - Street 2:
Practice Address - City:HARVEY
Practice Address - State:LA
Practice Address - Zip Code:70058-2377
Practice Address - Country:US
Practice Address - Phone:504-349-6900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-26
Last Update Date:2024-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA344216363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant