Basic Information
| Provider Information | |||||||||
| NPI: | 1003867656 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LAURINAITIS | ||||||||
| FirstName: | INGRID | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | P.A.-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1361 13TH AVE S | ||||||||
| Address2: | SUITE 170A | ||||||||
| City: | JACKSONVILLE BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322503233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042494456 | ||||||||
| FaxNumber: | 9042497703 | ||||||||
| Practice Location | |||||||||
| Address1: | 1361 13TH AVE S | ||||||||
| Address2: | SUITE 170A | ||||||||
| City: | JACKSONVILLE BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042494456 | ||||||||
| FaxNumber: | 9042497703 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 07/16/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 9107329 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 5601004336 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.