Provider Demographics
NPI:1972572808
Name:ZAGON, LAURA (PA)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:ZAGON
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1931 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:HADDON HEIGHTS
Mailing Address - State:NJ
Mailing Address - Zip Code:08035-1117
Mailing Address - Country:US
Mailing Address - Phone:704-607-4757
Mailing Address - Fax:
Practice Address - Street 1:1931 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:HADDON HEIGHTS
Practice Address - State:NJ
Practice Address - Zip Code:08035-1117
Practice Address - Country:US
Practice Address - Phone:704-607-4757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102257363A00000X
NJ25MP0048990363A00000X
MDC0004206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCS98433Medicare UPIN