Provider Demographics
NPI:1942376165
Name:TATAY, LORI J (PA-C)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:J
Last Name:TATAY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:J
Other - Last Name:TATAY-YOUNG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:5900 BYRON CENTER AVE SW
Mailing Address - Street 2:MEDICAL ADMINISTRATION
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-9606
Mailing Address - Country:US
Mailing Address - Phone:616-252-3243
Mailing Address - Fax:616-252-0260
Practice Address - Street 1:2122 HEALTH DR SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-9698
Practice Address - Country:US
Practice Address - Phone:616-252-5790
Practice Address - Fax:616-252-5793
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004900363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI160C976180OtherBCBSM
MI1942376165Medicaid
MI160C976180OtherBCBSM