Healthcare Provider Details

I. General information

NPI: 1104936046
Provider Name (Legal Business Name): LAUREE SUSAN KRUYER PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAUREE MICHALEC

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 03/03/2021
Certification Date: 03/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 NEW BERN AVE NEONATOLOGY DEPT.
RALEIGH NC
27610-1231
US

IV. Provider business mailing address

2920 HIGHWOODS BLVD
RALEIGH NC
27604-0010
US

V. Phone/Fax

Practice location:
  • Phone: 919-350-8545
  • Fax: 919-350-8146
Mailing address:
  • Phone: 877-498-4490
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number101181
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: