Provider Demographics
NPI:1548596232
Name:VIDAL, LORI A (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:LORI
Middle Name:A
Last Name:VIDAL
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:MISS
Other - First Name:LORI
Other - Middle Name:A
Other - Last Name:FISHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:310 STOCK ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:HANOVER
Mailing Address - State:PA
Mailing Address - Zip Code:17331-2276
Mailing Address - Country:US
Mailing Address - Phone:717-316-3555
Mailing Address - Fax:717-316-3556
Practice Address - Street 1:310 STOCK ST
Practice Address - Street 2:SUITE 4
Practice Address - City:HANOVER
Practice Address - State:PA
Practice Address - Zip Code:17331-2276
Practice Address - Country:US
Practice Address - Phone:717-316-3555
Practice Address - Fax:717-316-3556
Is Sole Proprietor?:No
Enumeration Date:2009-10-30
Last Update Date:2021-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP010540363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102440396Medicaid
PA170501ZEA5Medicare PIN