Healthcare Provider Details

I. General information

NPI: 1790111490
Provider Name (Legal Business Name): LAUREAN JADA WINSTON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2013
Last Update Date: 02/18/2021
Certification Date: 02/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 REGENCY PARK STE 100
O FALLON IL
62269-1887
US

IV. Provider business mailing address

321 REGENCY PARK STE 100
O FALLON IL
62269-1887
US

V. Phone/Fax

Practice location:
  • Phone: 618-416-7970
  • Fax:
Mailing address:
  • Phone: 618-416-7970
  • Fax: 618-416-7971

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number11502
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number55629
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA11166
License Number StateTX
# 4
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085004813
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: