Provider Demographics
NPI:1679883060
Name:MASTERSON, LORI (MS, PA-C)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:MASTERSON
Suffix:
Gender:F
Credentials:MS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1430 MAGLIANO DR
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33436-1106
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 S DIXIE HWY
Practice Address - Street 2:SUITE 411
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33432-5518
Practice Address - Country:US
Practice Address - Phone:561-922-6595
Practice Address - Fax:561-244-0506
Is Sole Proprietor?:No
Enumeration Date:2010-10-19
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101239363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant