Basic Information
| Provider Information | |||||||||
| NPI: | 1871955971 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FITZPATRICK | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FITZPATRICK RAYNER | ||||||||
| OtherFirstName: | LAURA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 22 WEST 15TH STREET | ||||||||
| Address2: | 1ST FLOOR | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5167193376 | ||||||||
| FaxNumber: | 5163218516 | ||||||||
| Practice Location | |||||||||
| Address1: | 22 WEST 15TH STREET | ||||||||
| Address2: | FL 1 | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5167193376 | ||||||||
| FaxNumber: | 5163218516 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2016 | ||||||||
| LastUpdateDate: | 07/22/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207N00000X | 303397-01 | NY | Y | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.