Provider Demographics
NPI:1306394317
Name:DIMACALI, LAWRENCE MICHAEL (PA-C)
Entity Type:Individual
Prefix:
First Name:LAWRENCE MICHAEL
Middle Name:
Last Name:DIMACALI
Suffix:
Gender:M
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 1:1600 STATE ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-4257
Mailing Address - Country:US
Mailing Address - Phone:503-540-6300
Mailing Address - Fax:503-540-6404
Practice Address - Street 1:1600 STATE ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-4257
Practice Address - Country:US
Practice Address - Phone:503-540-6300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-19
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA190503363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant