MEDICARE: DR. JEAN RENE LORIAL PA, FSA,MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	246ZC0007X	Surgical Assistant	21-263	WI
2	363AM0700X	Medical Physician Assistant	001660	PR
3	363AM0700X	Medical Physician Assistant	PACN21	FL
4	363AM0700X	Medical Physician Assistant	10338	AZ

General Provider Information

NPI Number	:	1427749639
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEAN RENE LORIAL PA, FSA,MD

Provider Business Mailing Address
First Line	:	6211 CARD BLVD
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46221-6102
Country	:	US
Telephone Number	:	812-887-6081
Fax Number	:

Provider Business Practice Location Address
First Line	:	5847 S 16TH ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85040-3512
Country	:	US
Telephone Number	:	602-609-4107
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/17/2023
Last Update Date	:	05/31/2025

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