Provider Demographics
NPI:1023388519
Name:RANCOURT, LORA MINA (PA-C)
Entity Type:Individual
Prefix:
First Name:LORA
Middle Name:MINA
Last Name:RANCOURT
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 31396
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598-8396
Mailing Address - Country:US
Mailing Address - Phone:925-939-8585
Mailing Address - Fax:925-933-2709
Practice Address - Street 1:2625 SHADELANDS DR
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-2512
Practice Address - Country:US
Practice Address - Phone:925-939-8585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-30
Last Update Date:2018-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA22045363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA22045OtherSTATE LICENSE
CAHD876ZMedicare PIN