Provider Demographics
NPI:1619949906
Name:GREENBERG, LORA S (PA)
Entity Type:Individual
Prefix:
First Name:LORA
Middle Name:S
Last Name:GREENBERG
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O.B #2 SUITE 739
Mailing Address - Street 2:5939 HARRY HINES BLVD
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75235-9258
Mailing Address - Country:US
Mailing Address - Phone:214-645-1942
Mailing Address - Fax:214-645-1900
Practice Address - Street 1:5939 HARRY HINES BLVD
Practice Address - Street 2:POB 2 SUITE 739
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-9258
Practice Address - Country:US
Practice Address - Phone:214-645-1942
Practice Address - Fax:214-645-1900
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2055363A00000X
TXPA06394363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P03916Medicare UPIN
AZ848632Medicaid
AZ100835Medicare ID - Type Unspecified