Provider Demographics
NPI:1710020367
Name:DAVIS, LORRAINE THERESA (MS, PA-C)
Entity Type:Individual
Prefix:MRS
First Name:LORRAINE
Middle Name:THERESA
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MS, PA-C
Other - Prefix:
Other - First Name:LORRAINE
Other - Middle Name:THERESA
Other - Last Name:CLEMENT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, PA-C, ATC
Mailing Address - Street 1:551 W LAYTON ST
Mailing Address - Street 2:
Mailing Address - City:OLATHE
Mailing Address - State:KS
Mailing Address - Zip Code:66061-6396
Mailing Address - Country:US
Mailing Address - Phone:714-944-7720
Mailing Address - Fax:
Practice Address - Street 1:3651 COLLEGE BLVD
Practice Address - Street 2:
Practice Address - City:LEAWOOD
Practice Address - State:KS
Practice Address - Zip Code:66211-1910
Practice Address - Country:US
Practice Address - Phone:913-218-0807
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPT796363A00000X, 363AM0700X, 363AS0400X
KS15-02452363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1710020367Medicaid
CA1710020367Medicaid