Provider Demographics
NPI:1902209372
Name:MIRELES, LAURA P (PA)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:P
Last Name:MIRELES
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1030 BENSDALE RD
Mailing Address - Street 2:
Mailing Address - City:PLEASANTON
Mailing Address - State:TX
Mailing Address - Zip Code:78064-2037
Mailing Address - Country:US
Mailing Address - Phone:830-569-6615
Mailing Address - Fax:830-569-6714
Practice Address - Street 1:1030 BENSDALE RD
Practice Address - Street 2:
Practice Address - City:PLEASANTON
Practice Address - State:TX
Practice Address - Zip Code:78064-2037
Practice Address - Country:US
Practice Address - Phone:830-569-6615
Practice Address - Fax:830-569-6714
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-30
Last Update Date:2018-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1119812363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1119812OtherNCCPA-NATIONAL COMMISSION ON CERTIFICATION OF PHYSICIAN ASSISTANTS
TX343316102Medicaid