Healthcare Provider Details

I. General information

NPI: 1598020109
Provider Name (Legal Business Name): LAURA ELIZABETH GREGORY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2012
Last Update Date: 07/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 8TH ST
RADFORD VA
24141-2426
US

IV. Provider business mailing address

202 8TH ST
RADFORD VA
24141-2426
US

V. Phone/Fax

Practice location:
  • Phone: 540-639-5188
  • Fax: 540-639-9215
Mailing address:
  • Phone: 540-639-5188
  • Fax: 540-639-9215

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0110003909
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: