Basic Information
| Provider Information | |||||||||
| NPI: | 1801382320 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAAG | ||||||||
| FirstName: | LAURA | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 415 BYERS RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | MIAMISBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453423684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9378662494 | ||||||||
| FaxNumber: | 9378668494 | ||||||||
| Practice Location | |||||||||
| Address1: | 415 BYERS RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | MIAMISBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9378662494 | ||||||||
| FaxNumber: | 9378668494 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2018 | ||||||||
| LastUpdateDate: | 01/14/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | RN.380043 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LA2200X | APRN.CNP.023105 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 0308820 | 05 | OH | MEDICAID |