=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417646936
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NSDR PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2023
-----------------------------------------------------
Last Update Date | 07/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2242 FORT WORTH AVE STE 115
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75211-1864
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-803-4466
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1764
-----------------------------------------------------
City | LINCOLN
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95648-1445
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-333-9557
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. LAURA PURDY
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 910-644-8373
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------