| NPI | 1033597505 |
|---|---|
| Former Name | LAURA WALLACE |
| Entity Type | Individual |
| Gender | Female |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA179418) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| Enumeration Date | 2015-05-15 |
| Last Update Date | 2020-07-20 |