Provider Demographics
NPI:1295767028
Name:PENO-GREEN, LAURA (MD)
Entity type:Individual
Prefix:DR
First Name:LAURA
Middle Name:
Last Name:PENO-GREEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2544 COURT DR STE D
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-3478
Mailing Address - Country:US
Mailing Address - Phone:980-834-5864
Mailing Address - Fax:704-864-0288
Practice Address - Street 1:2544 COURT DR STE D
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054
Practice Address - Country:US
Practice Address - Phone:980-834-5864
Practice Address - Fax:704-864-0288
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2018-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA042693207RP1001X, 207RP1001X
NC2018-01678207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease