Provider Demographics
NPI:1992810360
Name:WORTHINGTON, LAURA LEIGH (PA)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:LEIGH
Last Name:WORTHINGTON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13491 S BUGAI RD
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-8421
Mailing Address - Country:US
Mailing Address - Phone:231-947-4394
Mailing Address - Fax:
Practice Address - Street 1:13491 S BUGAI RD
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-8421
Practice Address - Country:US
Practice Address - Phone:231-947-4394
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004553363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical