Basic Information
| Provider Information | |||||||||
| NPI: | 1346542065 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ZANG | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | MATTSON | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | N.P. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MATTSON | ||||||||
| OtherFirstName: | LAURA | ||||||||
| OtherMiddleName: | LOUISE | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | FNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 26650 EUREKA RD | ||||||||
| Address2: | SUITE C-1 | ||||||||
| City: | TAYLOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481804835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349414991 | ||||||||
| FaxNumber: | 7349414919 | ||||||||
| Practice Location | |||||||||
| Address1: | 2500 HAMLIN DR | ||||||||
| Address2: | |||||||||
| City: | INKSTER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481412348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3135615100 | ||||||||
| FaxNumber: | 3135650309 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2010 | ||||||||
| LastUpdateDate: | 10/21/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 4704096784 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 0H24998 | 01 | MI | BCBS | OTHER | 1346542065 | 05 | MI | MEDICAID |