1407883283 NPI number — LAURA GINOZA PA-C

Table of content: LAURA GINOZA PA-C (NPI 1407883283)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407883283 NPI number — LAURA GINOZA PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GINOZA
Provider First Name:
LAURA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407883283
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/06/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
36115 SCHOOLCRAFT RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LIVONIA
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48150-1216
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-464-0887
Provider Business Mailing Address Fax Number:
734-402-0254

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18263 E 10 MILE RD
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
ROSEVILLE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48066-5805
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-464-0887
Provider Business Practice Location Address Fax Number:
734-402-0254
Provider Enumeration Date:
06/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA 01248 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 5601005561 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 480F37288 . This is a "BLUE CROSS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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