Provider Demographics
NPI:1124027396
Name:LORENZ, BETH WINIFRED (PA-C)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:WINIFRED
Last Name:LORENZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:BETH
Other - Middle Name:WINIFRED
Other - Last Name:COLEMAN LORENZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 655
Mailing Address - Street 2:
Mailing Address - City:MOULTONBORO
Mailing Address - State:NH
Mailing Address - Zip Code:03254-0655
Mailing Address - Country:US
Mailing Address - Phone:603-253-3178
Mailing Address - Fax:
Practice Address - Street 1:984 WHITTIER HIGHWAY
Practice Address - Street 2:
Practice Address - City:MOULTONBOROUGH
Practice Address - State:NH
Practice Address - Zip Code:03254
Practice Address - Country:US
Practice Address - Phone:603-476-2216
Practice Address - Fax:603-476-5396
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-19
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0210P363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30331636Medicaid
NHS27778Medicare UPIN
NH30331636Medicaid