Provider Demographics
NPI:1053390351
Name:STAVRAKIS, LAURA JEAN (PAC)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:JEAN
Last Name:STAVRAKIS
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:MS
Other - First Name:LAURA
Other - Middle Name:JEAN
Other - Last Name:CONLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PAC
Mailing Address - Street 1:125 N 6TH ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26301-2665
Mailing Address - Country:US
Mailing Address - Phone:304-624-7200
Mailing Address - Fax:304-624-4319
Practice Address - Street 1:399 EMILY DR
Practice Address - Street 2:
Practice Address - City:CLARKSBURG
Practice Address - State:WV
Practice Address - Zip Code:26301-5505
Practice Address - Country:US
Practice Address - Phone:304-624-4315
Practice Address - Fax:304-624-4319
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV01156363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
O55213Medicare UPIN
WVPA25802Medicare PIN