MEDICARE: LAUREN ELIZABETH STATON PTA

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	225200000X	Physical Therapy Assistant	2306605809	VA

General Provider Information

NPI Number	:	1497456321
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAUREN ELIZABETH STATON PTA

Provider Business Mailing Address
First Line	:	7310 LAKESHORE DR
Second Line	:
City	:	QUINTON
State	:	VA
Zip	:	23141-1155
Country	:	US
Telephone Number	:	804-614-1840
Fax Number	:

Provider Business Practice Location Address
First Line	:	4730 S LABURNUM AVE
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23231-2712
Country	:	US
Telephone Number	:	804-764-1000
Fax Number	:

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

Provider Enumeration Date	:	03/16/2023
Last Update Date	:	03/16/2023

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