Provider Demographics
NPI:1649422999
Name:MILLS, LORA L (PA)
Entity Type:Individual
Prefix:MS
First Name:LORA
Middle Name:L
Last Name:MILLS
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 1:2124 E BROADMOR DR
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-3025
Mailing Address - Country:US
Mailing Address - Phone:480-330-4031
Mailing Address - Fax:
Practice Address - Street 1:5250 E SOUTHERN AVE
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206
Practice Address - Country:US
Practice Address - Phone:602-955-1000
Practice Address - Fax:602-508-4830
Is Sole Proprietor?:No
Enumeration Date:2008-10-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019353363A00000X
MA6036363A00000X
CA53340363A00000X
CT3929363AM0700X
AZ4283363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ437602Medicaid