MEDICARE: MRS. LAURA A WILLCOX

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1255878971
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LAURA A WILLCOX

Provider Business Mailing Address
First Line	:	3530 SUMMERWAY DR
Second Line	:
City	:	COLLEGE STATION
State	:	TX
Zip	:	77845-7442
Country	:	US
Telephone Number	:	214-585-9109
Fax Number	:

Provider Business Practice Location Address
First Line	:	3530 SUMMERWAY DR
Second Line	:
City	:	COLLEGE STATION
State	:	TX
Zip	:	77845-7442
Country	:	US
Telephone Number	:	214-585-9109
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/20/2017
Last Update Date	:	01/20/2017

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