Provider Demographics
NPI:1871881649
Name:SHAMBO, LAUREL J (PA)
Entity type:Individual
Prefix:
First Name:LAUREL
Middle Name:J
Last Name:SHAMBO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2337
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13220-2337
Mailing Address - Country:US
Mailing Address - Phone:315-701-5607
Mailing Address - Fax:315-701-5608
Practice Address - Street 1:9732 STATE ROUTE 12
Practice Address - Street 2:
Practice Address - City:COPENHAGEN
Practice Address - State:NY
Practice Address - Zip Code:13626-2906
Practice Address - Country:US
Practice Address - Phone:315-688-2305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-14
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015328363A00000X
NYP80534363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03417452Medicaid
NY03417452Medicaid