Healthcare Provider Details

I. General information

NPI: 1972536779
Provider Name (Legal Business Name): LORI ANNE CARDWELL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 06/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 LILLY RD NE SUITE 100
OLYMPIA WA
98506-5117
US

IV. Provider business mailing address

PO BOX 368
OLYMPIA WA
98507-0368
US

V. Phone/Fax

Practice location:
  • Phone: 360-491-4211
  • Fax: 360-493-0407
Mailing address:
  • Phone: 360-491-8439
  • Fax: 360-491-6328

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA10003577
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: