Basic Information
| Provider Information | |||||||||
| NPI: | 1427584002 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | QUERIN | ||||||||
| FirstName: | LAUREN | ||||||||
| MiddleName: | BLAKE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD, MS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MASSIMO | ||||||||
| OtherFirstName: | LAUREN | ||||||||
| OtherMiddleName: | QUERIN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD, MS | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 170 MANNING DR | ||||||||
| Address2: | CB 7594 | ||||||||
| City: | CHAPEL HILL | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275144221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199666440 | ||||||||
| FaxNumber: | 9199663049 | ||||||||
| Practice Location | |||||||||
| Address1: | 170 MANNING DR | ||||||||
| Address2: | CB 7594 | ||||||||
| City: | CHAPEL HILL | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275144221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199666440 | ||||||||
| FaxNumber: | 9199663049 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2017 | ||||||||
| LastUpdateDate: | 04/07/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 227455 | NC | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207P00000X | 227455 | NC | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.