Provider Demographics
NPI:1710969597
Name:LORELLO, MICHAEL R (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:LORELLO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10900 W 44TH AVE UNIT 200
Mailing Address - Street 2:
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-2742
Mailing Address - Country:US
Mailing Address - Phone:720-548-1194
Mailing Address - Fax:303-423-7004
Practice Address - Street 1:3890 TAMPA RD
Practice Address - Street 2:SUITE 3404
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684-3676
Practice Address - Country:US
Practice Address - Phone:727-216-0505
Practice Address - Fax:727-789-8261
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-16
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC5-0012026363A00000X
NJ25MP00052700363A00000X
PAMA002676L363A00000X
FLPA9101788363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291311900Medicaid