Active NPI
Laurie Marguerite Mediavilla, P.A.-C
- Physician Assistant
- Colorado Springs, CO
National Provider Identifier
1568513000
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physician Assistant
- License
- PA.0001028
- Practice address
- 825 E Pikes Peak Ave
Colorado Springs, CO 80903-3624 - Phone
- (719) 776-8850
- Fax
- (719) 776-8854
- NPI assigned
- Jan 12, 2007
- Last updated
- Dec 16, 2019
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physician Assistant | 363A00000X | PA.0001028 | CO | Primary |
| Medical Physician Assistant | 363AM0700X | 1028 | CO |
Addresses
Primary practice location
825 E Pikes Peak Ave
Colorado Springs, CO 80903-3624
Mailing address
825 E Pikes Peak Ave
Colorado Springs, CO 80903-3624
Phone (719) 776-8850
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 71906240 | Medicaid | CO |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Physician Assistant
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 1028 | CO | MD | Addiction (Substance Use Disorder) Counselor |
| PA.0001028 | CO | MD | Physician Assistant |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1168560000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1576454400000",
"number": "1568513000",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "825 E PIKES PEAK AVE",
"city": "COLORADO SPRINGS",
"state": "CO",
"postal_code": "809033624",
"telephone_number": "719-776-8850",
"fax_number": "719-776-8854"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "825 E PIKES PEAK AVE",
"city": "COLORADO SPRINGS",
"state": "CO",
"postal_code": "809033624",
"telephone_number": "719-776-8850",
"fax_number": "719-776-8854"
}
],
"practiceLocations": [],
"basic": {
"last_name": "MEDIAVILLA",
"first_name": "LAURIE",
"middle_name": "MARGUERITE",
"credential": "P.A.-C",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2007-01-12",
"last_updated": "2019-12-16",
"certification_date": "2019-12-16",
"status": "A"
},
"taxonomies": [
{
"code": "363A00000X",
"taxonomy_group": "",
"desc": "Physician Assistant",
"state": "CO",
"license": "PA.0001028",
"primary": true
},
{
"code": "363AM0700X",
"taxonomy_group": "",
"desc": "Physician Assistant, Medical",
"state": "CO",
"license": "1028",
"primary": false
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "71906240",
"state": "CO"
}
],
"endpoints": [],
"other_names": []
}Other providers in Colorado Springs, CO
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 16, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.