Laura Provenzano, PA-C

Primary specialty

Physician AssistantTaxonomy code 363A00000X

License

0110004424 Issued in VA

Practice address

3117 Duke St
Alexandria, VA 22314-4518

Phone

(703) 751-8800

NPI assigned

Dec 10, 2012

Last updated

Dec 12, 2017By the provider in NPPES

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Frances Mahon Deaconess Hospital

  • Critical Access Hospital
  • Glasgow, MT
  • NPI 1689685323
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1355097600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1513036800000",
    "number": "1396080800",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1563 ONYX DR UNIT 205",
            "city": "MC LEAN",
            "state": "VA",
            "postal_code": "221023945",
            "telephone_number": "703-585-5951"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3117 DUKE ST",
            "city": "ALEXANDRIA",
            "state": "VA",
            "postal_code": "223144518",
            "telephone_number": "703-751-8800"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PROVENZANO",
        "first_name": "LAURA",
        "credential": "PA-C",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2012-12-10",
        "last_updated": "2017-12-12",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "VA",
            "license": "0110004424",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "STATE LICENSE",
            "identifier": "0110004424",
            "state": "VA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Physician Assistant in Alexandria, VA
• Providers in Alexandria, VA by specialty
• Physician Assistant in Virginia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 12, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.