MEDICARE: LAURA PROVENZANO PA-C

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	363A00000X	Physician Assistant	0110004424	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0110004424	OTHER	VA	STATE LICENSE

General Provider Information

NPI Number	:	1396080800
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA PROVENZANO PA-C

Provider Business Mailing Address
First Line	:	1563 ONYX DR UNIT 205
Second Line	:
City	:	MC LEAN
State	:	VA
Zip	:	22102-3945
Country	:	US
Telephone Number	:	703-585-5951
Fax Number	:

Provider Business Practice Location Address
First Line	:	3117 DUKE ST
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22314-4518
Country	:	US
Telephone Number	:	703-751-8800
Fax Number	:

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

Provider Enumeration Date	:	12/10/2012
Last Update Date	:	12/12/2017

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