Provider Demographics
NPI:1336278407
Name:LORENTZEN, CHRISTIAN ANTHONY (R-PAC)
Entity Type:Individual
Prefix:MR
First Name:CHRISTIAN
Middle Name:ANTHONY
Last Name:LORENTZEN
Suffix:
Gender:M
Credentials:R-PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 RUDYS LN
Mailing Address - Street 2:
Mailing Address - City:CORAM
Mailing Address - State:NY
Mailing Address - Zip Code:11727-2324
Mailing Address - Country:US
Mailing Address - Phone:631-513-9887
Mailing Address - Fax:
Practice Address - Street 1:207 GLEN COVE AVE
Practice Address - Street 2:
Practice Address - City:SEA CLIFF
Practice Address - State:NY
Practice Address - Zip Code:11579-1437
Practice Address - Country:US
Practice Address - Phone:631-265-5858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007869363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical