Provider Demographics
NPI:1477573418
Name:LORAH, BRADLEY
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:LORAH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 N CEDAR CREST BLVD STE 411
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18104-2323
Mailing Address - Country:US
Mailing Address - Phone:484-629-2282
Mailing Address - Fax:
Practice Address - Street 1:334 MAIN ST
Practice Address - Street 2:STE 1
Practice Address - City:DICKSON CITY
Practice Address - State:PA
Practice Address - Zip Code:18519-1620
Practice Address - Country:US
Practice Address - Phone:570-307-1767
Practice Address - Fax:570-307-1770
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA003220L363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMA003220LOtherSTATE LICENSE
PA050681MYQMedicare ID - Type Unspecified