Healthcare Provider Details

I. General information

NPI: 1538159298
Provider Name (Legal Business Name): LORI LOUISE MARTIN PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2005
Last Update Date: 05/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

576 JEFFERSON AVE PRIMARY CARE CLINIC RM 330
FORT EUSTIS VA
23604-1602
US

IV. Provider business mailing address

797 S FAIR OAKS AVE
PASADENA CA
91105-2617
US

V. Phone/Fax

Practice location:
  • Phone: 757-314-7613
  • Fax:
Mailing address:
  • Phone: 310-621-6439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA15787
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: