Provider Demographics
NPI:1346236460
Name:PHILLIPS, LORITA LYNN (PA)
Entity Type:Individual
Prefix:
First Name:LORITA
Middle Name:LYNN
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:LYNN
Other - Last Name:PHILLPS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6925 CHELSEA DR NE
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-1432
Mailing Address - Country:US
Mailing Address - Phone:319-550-7694
Mailing Address - Fax:
Practice Address - Street 1:200 HAWKINS DR
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-1009
Practice Address - Country:US
Practice Address - Phone:319-384-6254
Practice Address - Fax:319-353-6399
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001308363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA25413OtherWELLMARK BCBS
IA25413OtherWELLMARK BCBS
P16370Medicare UPIN