Healthcare Provider Details

I. General information

NPI: 1336090836
Provider Name (Legal Business Name): BRIAN LAURA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2026
Last Update Date: 03/03/2026
Certification Date: 03/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 PROSPECT AVE STE 907
HACKENSACK NJ
07601-1989
US

IV. Provider business mailing address

6301 RIVERDALE AVE
BRONX NY
10471-1046
US

V. Phone/Fax

Practice location:
  • Phone: 201-342-2550
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: