Basic Information
| Provider Information | |||||||||
| NPI: | 1629707872 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STAJDUHAR | ||||||||
| FirstName: | LAURA | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 318 KRUGER RD | ||||||||
| Address2: | |||||||||
| City: | ONALASKA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985709709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2533189736 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2690 NE KRESKY AVE | ||||||||
| Address2: | |||||||||
| City: | CHEHALIS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985322412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603309595 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2022 | ||||||||
| LastUpdateDate: | 09/29/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | AP61319998 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | AP61319998 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 2215897 | 05 | WA | MEDICAID |