Provider Demographics
NPI:1730433301
Name:LYSK, LAURA (PA-C)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:LYSK
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 1:5401 TWIN KNOLLS RD STE 11
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-3257
Mailing Address - Country:US
Mailing Address - Phone:443-979-7819
Mailing Address - Fax:443-979-7846
Practice Address - Street 1:5401 TWIN KNOLLS RD STE 11
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-3257
Practice Address - Country:US
Practice Address - Phone:443-979-7819
Practice Address - Fax:443-979-7846
Is Sole Proprietor?:No
Enumeration Date:2012-11-05
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0004898363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant