Provider Demographics
NPI:1871057141
Name:FUNDINGSLAND, LAURA CHRISTINA (PA-C)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:CHRISTINA
Last Name:FUNDINGSLAND
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 CONVENT AVE APT 32
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10027-7511
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1106 PACIFIC ST
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-3302
Practice Address - Country:US
Practice Address - Phone:805-546-9500
Practice Address - Fax:805-546-9699
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-30
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
CA57782363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty