Healthcare Provider Details

I. General information

NPI: 1427749639
Provider Name (Legal Business Name): JEAN RENE LORIAL PA, FSA,MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2023
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5847 S 16TH ST
PHOENIX AZ
85040-3512
US

IV. Provider business mailing address

6211 CARD BLVD
INDIANAPOLIS IN
46221-6102
US

V. Phone/Fax

Practice location:
  • Phone: 602-609-4107
  • Fax:
Mailing address:
  • Phone: 812-887-6081
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number001660
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPACN21
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number10338
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number21-263
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: