1740619311 NPI number — MRS. SHAE LYNN LOWRY PA-C

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740619311 NPI number — MRS. SHAE LYNN LOWRY PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LOWRY
Provider First Name:
SHAE
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MRS.
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:
BURKETT
Provider Other First Name:
SHAE
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1740619311
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/14/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
640 KOLTER DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDIANA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15701-3570
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-357-7196
Provider Business Mailing Address Fax Number:
724-357-7279

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1265 WAYNE AVE STE 107
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDIANA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15701-3501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-463-9702
Provider Business Practice Location Address Fax Number:
724-463-1046
Provider Enumeration Date:
11/05/2013

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:  MA056592 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 103143430 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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