MEDICARE: MS. LAURA RUTH DUFFY 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	CA21210	CA
2	363AS0400X	Surgical Physician Assistant	CA21210	CA

General Provider Information

NPI Number	:	1720288087
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LAURA RUTH DUFFY PA-C

Provider Business Mailing Address
First Line	:	1643 6TH AVE
Second Line	:	#204
City	:	SAN DIEGO
State	:	CA
Zip	:	92101-2757
Country	:	US
Telephone Number	:	442-222-0298
Fax Number	:

Provider Business Practice Location Address
First Line	:	34800 BOB WILSON DR STE 201
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92134-2757
Country	:	US
Telephone Number	:	619-532-6950
Fax Number	:	619-532-5501

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

Provider Enumeration Date	:	07/24/2007
Last Update Date	:	06/07/2023

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