Healthcare Provider Details

I. General information

NPI: 1194831933
Provider Name (Legal Business Name): LAUREL H. LAN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAUREL C. HILDERBRANDT

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 07/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7500 IRON BAR LN SUITE 215
GAINESVILLE VA
20155-3603
US

IV. Provider business mailing address

7500 IRON BAR LN SUITE 215
GAINESVILLE VA
20155-3603
US

V. Phone/Fax

Practice location:
  • Phone: 571-261-1234
  • Fax: 571-261-2235
Mailing address:
  • Phone: 571-261-1234
  • Fax: 571-261-2235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA030409
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number011914-1
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110002978
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: