Provider Demographics
NPI:1144256124
Name:WILK, LAURA D (PA-C)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:D
Last Name:WILK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:250 PATCHOGUE YAPHANK RD
Mailing Address - Street 2:SUITE 12
Mailing Address - City:EAST PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-4800
Mailing Address - Country:US
Mailing Address - Phone:631-289-7474
Mailing Address - Fax:
Practice Address - Street 1:250 PATCHOGUE YAPHANK RD
Practice Address - Street 2:SUITE 12
Practice Address - City:EAST PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-4800
Practice Address - Country:US
Practice Address - Phone:631-289-7474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY009592363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY8304L70281Medicare PIN