Healthcare Provider Details

I. General information

NPI: 1992057467
Provider Name (Legal Business Name): LAUREN A AYUSO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LAUREN A SACKETT

II. Dates (important events)

Enumeration Date: 10/09/2012
Last Update Date: 04/05/2022
Certification Date: 04/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6401 FRANCE AVE S
EDINA MN
55435-2104
US

IV. Provider business mailing address

1605 W FAIRBANKS AVE
WINTER PARK FL
32789-4603
US

V. Phone/Fax

Practice location:
  • Phone: 952-924-5000
  • Fax:
Mailing address:
  • Phone: 407-975-0200
  • Fax: 407-975-0209

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA 9106831
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: