Basic Information
| Provider Information | |||||||||
| NPI: | 1548676612 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WASILEWSKI | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | STAYROOK | ||||||||
| OtherFirstName: | LAURA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 75420 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212755420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7033836469 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 820 SIR THOMAS CT | ||||||||
| Address2: | |||||||||
| City: | HARRISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 171094839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7176529555 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2014 | ||||||||
| LastUpdateDate: | 04/06/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 01100004662 | VA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | OA005969 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.