Healthcare Provider Details

I. General information

NPI: 1679619613
Provider Name (Legal Business Name): LAURA REMAKLUS DEWITZ PAC, MHS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 09/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 INDEPENDENCE PKWY SUITE 100
CHESAPEAKE VA
23320-5205
US

IV. Provider business mailing address

640 INDEPENDENCE PKWY SUITE 100
CHESAPEAKE VA
23320-5205
US

V. Phone/Fax

Practice location:
  • Phone: 757-420-0530
  • Fax: 757-420-0488
Mailing address:
  • Phone: 757-420-0530
  • Fax: 757-420-0488

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110001403
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: