Provider Demographics
NPI:1902964554
Name:REIDY, LAURA ROBIN (PA)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:ROBIN
Last Name:REIDY
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:PO BOX 22025
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33622-2025
Mailing Address - Country:US
Mailing Address - Phone:941-477-4007
Mailing Address - Fax:877-239-7174
Practice Address - Street 1:315 NOKOMIS AVE S
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-2417
Practice Address - Country:US
Practice Address - Phone:941-477-4007
Practice Address - Fax:877-239-7174
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9115411363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1902964554Medicaid