Healthcare Provider Details

I. General information

NPI: 1013091594
Provider Name (Legal Business Name): LAURA BRECKENRIDGE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 SNEATH LN SUITE 104
SAN BRUNO CA
94066-2308
US

IV. Provider business mailing address

308 22ND AVE
SAN MATEO CA
94403-1710
US

V. Phone/Fax

Practice location:
  • Phone: 650-873-4545
  • Fax: 650-873-4544
Mailing address:
  • Phone: 650-357-7971
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License NumberG64476
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: