Provider Demographics
NPI:1710910252
Name:DECKER, LORI (PA)
Entity Type:Individual
Prefix:MS
First Name:LORI
Middle Name:
Last Name:DECKER
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 1:324 10TH AVE STE 154
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84103-2876
Mailing Address - Country:US
Mailing Address - Phone:801-408-8666
Mailing Address - Fax:801-322-0567
Practice Address - Street 1:324 10TH AVE STE 154
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84103-2876
Practice Address - Country:US
Practice Address - Phone:801-408-8666
Practice Address - Fax:801-322-0567
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1002411206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTS33401Medicare UPIN
UT005544506Medicare PIN