Provider Demographics
NPI:1932139839
Name:LOLLATHIN, DOROTHY B (PA-C)
Entity Type:Individual
Prefix:
First Name:DOROTHY
Middle Name:B
Last Name:LOLLATHIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 REID PARKWAY
Mailing Address - Street 2:MEDICAL STAFF SERVICE
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-1157
Mailing Address - Country:US
Mailing Address - Phone:765-935-8905
Mailing Address - Fax:765-939-4200
Practice Address - Street 1:1400 HIGHLAND RD STE 1
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-8810
Practice Address - Country:US
Practice Address - Phone:765-935-8905
Practice Address - Fax:765-939-4200
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.002298RX363A00000X
IN10003160A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000181581OtherUNISON MEDICAID
OH0498377OtherMOLINA MEDICAID
P00278526OtherRR MEDICARE
000000175652OtherANTHEM BCBS
001769308OtherMOUNTAIN STATE BCBS
OH0075679Medicaid
WV1068920Medicaid
OH293560617OtherTRI CARE
OHLOPA26161Medicare PIN
OH000000181581OtherUNISON MEDICAID