Provider Demographics
NPI:1023094794
Name:PINO, LAURA AMANDA (MS, PA-C)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:AMANDA
Last Name:PINO
Suffix:
Gender:F
Credentials:MS, PA-C
Other - Prefix:MISS
Other - First Name:LAURA
Other - Middle Name:AMANDA
Other - Last Name:HABER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS,PA-C
Mailing Address - Street 1:301 LIPPINCOTT DR STE 410
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-4197
Mailing Address - Country:US
Mailing Address - Phone:856-355-0340
Mailing Address - Fax:856-355-0330
Practice Address - Street 1:147 E 3RD ST
Practice Address - Street 2:SUITE 2
Practice Address - City:MOORESTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08057-2924
Practice Address - Country:US
Practice Address - Phone:856-234-2500
Practice Address - Fax:856-234-3907
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA053350363A00000X
NY008803363A00000X
NJ25MP00097800363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant