Provider Demographics
NPI:1699708818
Name:SKORACKI, LAURA DAWN GATSOS (PA-C)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:DAWN GATSOS
Last Name:SKORACKI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:DAWN
Other - Last Name:GATSOS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:320 W 10TH AVE
Mailing Address - Street 2:B250
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43210-1280
Mailing Address - Country:US
Mailing Address - Phone:614-366-5174
Mailing Address - Fax:
Practice Address - Street 1:460 W 10TH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210
Practice Address - Country:US
Practice Address - Phone:614-293-8074
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02098363A00000X
OH50004177363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX180584801Medicaid
TX87N109OtherBCBS
TX970011588OtherRR MEDICARE
TX87N109OtherBCBS