Provider Demographics
NPI:1467449835
Name:STACKOW, LORI A (PAC)
Entity Type:Individual
Prefix:MRS
First Name:LORI
Middle Name:A
Last Name:STACKOW
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:A
Other - Last Name:RUDDEROW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:1512 W KIRBY PL
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-3822
Mailing Address - Country:US
Mailing Address - Phone:318-626-0177
Mailing Address - Fax:
Practice Address - Street 1:1541 KINGS HWY
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4228
Practice Address - Country:US
Practice Address - Phone:318-626-0000
Practice Address - Fax:318-629-4833
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA10687363A00000X
LA332160363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA49008OtherDEPT OF LABOR AND INDUSTR
WA8434896Medicaid
ID004385800Medicaid
TX153449704Medicaid
IDPAJB6OtherBLUE CROSS OF ID
ID000010017182OtherREGENCE BS OF ID
601417200OtherDEEIOC
ID004385800Medicaid
0595810002Medicare NSC
IDPAJB6OtherBLUE CROSS OF ID
S24795Medicare UPIN
ID1373881Medicare Oscar/Certification
601417200OtherDEEIOC
TX153449704Medicaid
TX00106WMedicare PIN
ID1665201Medicare PIN