Provider Demographics
NPI:1558378372
Name:WORTHAM, LORI J (PA-C)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:J
Last Name:WORTHAM
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 1:940 E 3RD ST STE 215
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-3251
Mailing Address - Country:US
Mailing Address - Phone:307-237-5510
Mailing Address - Fax:307-237-0607
Practice Address - Street 1:940 E 3RD ST STE 215
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-3251
Practice Address - Country:US
Practice Address - Phone:307-237-5510
Practice Address - Fax:307-237-0607
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA450363A00000X
WY399363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806739400Medicaid
ID1667343Medicare ID - Type Unspecified