1669773925 NPI number — DARIA ANN LAURSEN ARNP

Table of content: DARIA ANN LAURSEN ARNP (NPI 1669773925)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669773925 NPI number — DARIA ANN LAURSEN ARNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LAURSEN
Provider First Name:
DARIA
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ARNP
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:
1669773925
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/27/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12 IROQUOIS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SARATOGA SPRINGS
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12866-3722
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3043 STATE ROUTE 4
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUDSON FALLS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12839-9632
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-747-8243
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/03/2010

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: 363LP0808X , with the licence number:  F402107-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000428405001 . This is a "BLUESHIELD OF NORTHEASTERN NY" identifier . This identifiers is of the category "OTHER".
  • Identifier: P01772165 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: J400347768 . This is a "MEDICARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 544623 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 402107 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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