Provider Demographics
NPI:1922157957
Name:LOCKWOOD, GLORIA (C-OPA)
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:
Last Name:LOCKWOOD
Suffix:
Gender:F
Credentials:C-OPA
Other - Prefix:
Other - First Name:GLORIA
Other - Middle Name:
Other - Last Name:KENOWITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:140 24TH ST S
Mailing Address - Street 2:PO BOX 8005
Mailing Address - City:WISCONSIN RAPIDS
Mailing Address - State:WI
Mailing Address - Zip Code:54494-1906
Mailing Address - Country:US
Mailing Address - Phone:715-424-1881
Mailing Address - Fax:715-423-1602
Practice Address - Street 1:140 24TH ST S
Practice Address - Street 2:
Practice Address - City:WISCONSIN RAPIDS
Practice Address - State:WI
Practice Address - Zip Code:54494-1906
Practice Address - Country:US
Practice Address - Phone:715-424-1881
Practice Address - Fax:715-423-1602
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI51120-030363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical