Provider Demographics
NPI:1699856534
Name:WILLINGMYRE, LAURA SANDRA (MD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:SANDRA
Last Name:WILLINGMYRE
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:
Other - Last Name:WILLINGMYRE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 188
Mailing Address - Street 2:
Mailing Address - City:MARANA
Mailing Address - State:AZ
Mailing Address - Zip Code:85653-0188
Mailing Address - Country:US
Mailing Address - Phone:520-682-4111
Mailing Address - Fax:
Practice Address - Street 1:2355 N WYATT DR STE 101
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-2120
Practice Address - Country:US
Practice Address - Phone:520-616-4948
Practice Address - Fax:520-616-4958
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ43889207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1209701Medicaid
NJ1209701Medicaid
NJ600574ABNMedicare ID - Type Unspecified