Provider Demographics
NPI:1053013292
Name:LAU, CHARISSA
Entity type:Individual
Prefix:
First Name:CHARISSA
Middle Name:
Last Name:LAU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7903 NW 14TH CT
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98665-6037
Mailing Address - Country:US
Mailing Address - Phone:360-910-0804
Mailing Address - Fax:
Practice Address - Street 1:505 S MAIN ST STE 525
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4553
Practice Address - Country:US
Practice Address - Phone:714-509-8547
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-21
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program