Provider Demographics
NPI:1558454066
Name:LAGERQUIST, LORI JANE (PA-C)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:JANE
Last Name:LAGERQUIST
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:LORI
Other - Middle Name:JANE
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:435 S CRYSTAL ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BUTTE
Mailing Address - State:MT
Mailing Address - Zip Code:59701-1506
Mailing Address - Country:US
Mailing Address - Phone:406-496-3600
Mailing Address - Fax:406-496-3653
Practice Address - Street 1:435 S CRYSTAL ST
Practice Address - Street 2:SUITE 200
Practice Address - City:BUTTE
Practice Address - State:MT
Practice Address - Zip Code:59701-1506
Practice Address - Country:US
Practice Address - Phone:406-496-3600
Practice Address - Fax:406-496-3653
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2017-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT58 (PA-C)207Q00000X
MT58363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0431847Medicaid
MT090173OtherBCBS OF MT
MT090173OtherBCBS OF MT
MTR10563Medicare UPIN