Provider Demographics
NPI:1912338872
Name:HAMILTON, LORI C (PA-C)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:C
Last Name:HAMILTON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1373 E CASSITY DR
Mailing Address - Street 2:
Mailing Address - City:TOOELE
Mailing Address - State:UT
Mailing Address - Zip Code:84074-4107
Mailing Address - Country:US
Mailing Address - Phone:907-947-6765
Mailing Address - Fax:
Practice Address - Street 1:1373 E CASSITY DR
Practice Address - Street 2:
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-4107
Practice Address - Country:US
Practice Address - Phone:907-947-6765
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-03
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA1659363A00000X
UT10332057-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT10332057-1206OtherLICENSE
AK1603011Medicaid
NV1912338872Medicaid