Provider Demographics
NPI:1699061671
Name:GLADDEN, LAURA BOYLE (PA-C)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:BOYLE
Last Name:GLADDEN
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 1:4692 BROWNSBORO RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-3410
Mailing Address - Country:US
Mailing Address - Phone:336-251-1114
Mailing Address - Fax:336-251-1116
Practice Address - Street 1:4692 BROWNSBORO RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-3410
Practice Address - Country:US
Practice Address - Phone:336-251-1114
Practice Address - Fax:336-251-1116
Is Sole Proprietor?:No
Enumeration Date:2011-06-28
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-02945363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNC1455AMedicare PIN