Basic Information
| Provider Information | |||||||||
| NPI: | 1619980976 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DELORME | ||||||||
| FirstName: | LAUREL | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 248 | ||||||||
| Address2: | |||||||||
| City: | ELLICOTTVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 147310248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166999032 | ||||||||
| FaxNumber: | 7166999035 | ||||||||
| Practice Location | |||||||||
| Address1: | 8003 BREWERTON RD | ||||||||
| Address2: | |||||||||
| City: | CICERO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130399528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3152884006 | ||||||||
| FaxNumber: | 3152884760 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2006 | ||||||||
| LastUpdateDate: | 08/27/2013 | ||||||||
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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 | 363A00000X | 009587 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 03448762 | 05 | NY | MEDICAID |