Healthcare Provider Details

I. General information

NPI: 1295385920
Provider Name (Legal Business Name): LORENA MCCLURE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2019
Last Update Date: 03/18/2020
Certification Date: 03/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 WAVERLY AVE APT 413
PATCHOGUE NY
11772-8301
US

IV. Provider business mailing address

77 WAVERLY AVE APT 413
PATCHOGUE NY
11772-8301
US

V. Phone/Fax

Practice location:
  • Phone: 917-202-0092
  • Fax:
Mailing address:
  • Phone: 917-202-0092
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number024861
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: