Healthcare Provider Details

I. General information

NPI: 1811213945
Provider Name (Legal Business Name): LAURA MICHELLE DESTRO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2010
Last Update Date: 04/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1555 SOQUEL DR
SANTA CRUZ CA
95065-1705
US

IV. Provider business mailing address

1555 SOQUEL DR
SANTA CRUZ CA
95065-1705
US

V. Phone/Fax

Practice location:
  • Phone: 831-462-7700
  • Fax:
Mailing address:
  • Phone: 831-462-7700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA121227
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: