Provider Demographics
NPI:1629446661
Name:EBINGER, LORI KATHERINE (PA-C)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:KATHERINE
Last Name:EBINGER
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 1:372 S EAGLE RD # 126
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-5908
Mailing Address - Country:US
Mailing Address - Phone:208-302-6450
Mailing Address - Fax:208-302-6455
Practice Address - Street 1:74 N FISHER PARK WAY
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616
Practice Address - Country:US
Practice Address - Phone:208-391-7210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-08
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1278363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant