MEDICARE: LAURA LEE KUSTABORDER PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	MA054247	PA

General Provider Information

NPI Number	:	1821190240
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA LEE KUSTABORDER PA-C

Provider Business Mailing Address
First Line	:	119 OCALA TRAIL DR
Second Line	:
City	:	PITTSBURGH
State	:	PA
Zip	:	15235-3531
Country	:	US
Telephone Number	:	412-874-7129
Fax Number	:

Provider Business Practice Location Address
First Line	:	5115 CENTRE AVE
Second Line	:	HILLMAN CANCER CENTER, 2ND FLOOR
City	:	PITTSBURGH
State	:	PA
Zip	:	15232-1301
Country	:	US
Telephone Number	:	412-864-7930
Fax Number	:	412-623-2540

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/05/2006
Last Update Date	:	04/03/2013

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