Provider Demographics
NPI:1902679160
Name:LAUBER, LANDON
Entity type:Individual
Prefix:
First Name:LANDON
Middle Name:
Last Name:LAUBER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 HOPE BLVD
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:IN
Mailing Address - Zip Code:46563-1253
Mailing Address - Country:US
Mailing Address - Phone:574-555-5555
Mailing Address - Fax:
Practice Address - Street 1:1915 LAKE AVE
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:IN
Practice Address - Zip Code:46563-9366
Practice Address - Country:US
Practice Address - Phone:574-948-4911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-31
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28243465A163WS0200X
IN149768367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WS0200XNursing Service ProvidersRegistered NurseSchool