Healthcare Provider Details

I. General information

NPI: 1174521363
Provider Name (Legal Business Name): LAURA ELLEN STAFF MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 09/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 WEMBLEY CT STE 101
ALBANY NY
12205-3891
US

IV. Provider business mailing address

22 RIDGEFIELD ST
ALBANY NY
12208-2908
US

V. Phone/Fax

Practice location:
  • Phone: 518-869-4300
  • Fax: 518-869-8386
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number198187
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: