Provider Demographics
NPI:1972536779
Name:CARDWELL, LORI ANNE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:LORI
Middle Name:ANNE
Last Name:CARDWELL
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:PO BOX 368
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98507-0368
Mailing Address - Country:US
Mailing Address - Phone:360-491-8439
Mailing Address - Fax:360-491-6328
Practice Address - Street 1:615 LILLY RD NE
Practice Address - Street 2:SUITE 100
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5117
Practice Address - Country:US
Practice Address - Phone:360-491-4211
Practice Address - Fax:360-493-0407
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003577363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8505299Medicaid
WA8505299Medicaid