Provider Demographics
NPI:1275585416
Name:MANFRE-CONAHAN, LORIANN M IV (PAC)
Entity Type:Individual
Prefix:
First Name:LORIANN
Middle Name:M
Last Name:MANFRE-CONAHAN
Suffix:IV
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 ELECTRIC ST
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18509-1843
Mailing Address - Country:US
Mailing Address - Phone:570-344-9684
Mailing Address - Fax:
Practice Address - Street 1:959 WYOMING AVE
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18509-3023
Practice Address - Country:US
Practice Address - Phone:570-344-9684
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA051950363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAQ29202Medicare UPIN
PA085619S63Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER