=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932409380
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA RENEE LAURION PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2010
-----------------------------------------------------
Last Update Date | 11/30/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 BOONE RD
-----------------------------------------------------
City | BREMERTON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98312-1894
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-471-2508
-----------------------------------------------------
Fax | 360-476-2580
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 BOONE RD
-----------------------------------------------------
City | BREMERTON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98312-1898
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-849-9111
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2083X0100X
-----------------------------------------------------
Taxonomy Name | Occupational Medicine Physician
-----------------------------------------------------
License Number | PA60193386
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | PA.60193386
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------