1003893108 NPI number — MS. LORI A NILAND PA-C

Table of content: MS. LORI A NILAND PA-C (NPI 1003893108)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003893108 NPI number — MS. LORI A NILAND PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NILAND
Provider First Name:
LORI
Provider Middle Name:
A
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DOREN
Provider Other First Name:
LORI
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PAC-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1003893108
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/08/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 16023
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEWISTON
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04243-9503
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-396-8600
Provider Business Mailing Address Fax Number:
603-692-6040

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22 BRAMHALL STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-662-2934
Provider Business Practice Location Address Fax Number:
207-662-6389
Provider Enumeration Date:
12/29/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA-620 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 0859 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA620 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3071700 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
  • Identifier: P01038297 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 30332527 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".




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