Healthcare Provider Details

I. General information

NPI: 1760968713
Provider Name (Legal Business Name): LAURA WAIALAE PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2018
Last Update Date: 06/03/2020
Certification Date: 06/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 MEDICAL PARK SUITE 101
WHEELING WV
26003
US

IV. Provider business mailing address

10 MEDICAL PARK SUITE 101
WHEELING WV
26003
US

V. Phone/Fax

Practice location:
  • Phone: 304-243-3889
  • Fax: 304-243-8802
Mailing address:
  • Phone: 304-243-3889
  • Fax: 304-243-8802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2199
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: