Provider Demographics
NPI:1134288251
Name:CLARK, LORI A (CRNA)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:A
Last Name:CLARK
Suffix:
Gender:F
Credentials:CRNA
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 5520
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18015-0520
Mailing Address - Country:US
Mailing Address - Phone:610-954-5810
Mailing Address - Fax:610-954-5480
Practice Address - Street 1:801 OSTRUM ST
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18015-1000
Practice Address - Country:US
Practice Address - Phone:610-954-5810
Practice Address - Fax:610-954-5480
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN-507355-L163W00000X
PA076891367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1580856OtherGATEWAY
PA1924485OtherFIRST PRIORITY
PA11802986OtherCAQH
PA104166OtherGEISINGER
PA50065227OtherCAPITAL ADVANTAGE
PA9696443OtherAETNA
PA1924485OtherHIGHMARK
PA1027796550001Medicaid
PA2792759000OtherIBC
PA1027796550001Medicaid
PAP00410302Medicare PIN