Provider Demographics
NPI:1518918341
Name:STOCKDALE, LORI HARRIS (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:LORI
Middle Name:HARRIS
Last Name:STOCKDALE
Suffix:
Gender:F
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 1:1812 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-3000
Mailing Address - Country:US
Mailing Address - Phone:334-794-2825
Mailing Address - Fax:334-793-5050
Practice Address - Street 1:1812 E MAIN ST
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-3000
Practice Address - Country:US
Practice Address - Phone:334-794-2825
Practice Address - Fax:334-793-5050
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2018-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004359363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51000527OtherBLUE CROSS & BLUE SHIELD
AL51000529OtherBLUE CROSS & BLUE SHIELD
AL51000528OtherBLUE CROSS & BLUE SHIELD
AL51000527OtherBLUE CROSS & BLUE SHIELD
AL051555474STOMedicare ID - Type Unspecified
WAG8928536Medicare PIN