Provider Demographics
NPI:1992841407
Name:CALLAS, LORRAINE (ANP)
Entity Type:Individual
Prefix:
First Name:LORRAINE
Middle Name:
Last Name:CALLAS
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 HIDDEN POND PATH
Mailing Address - Street 2:
Mailing Address - City:WADING RIVER
Mailing Address - State:NY
Mailing Address - Zip Code:11792-2175
Mailing Address - Country:US
Mailing Address - Phone:631-397-0012
Mailing Address - Fax:
Practice Address - Street 1:90 HIDDEN POND PATH
Practice Address - Street 2:
Practice Address - City:WADING RIVER
Practice Address - State:NY
Practice Address - Zip Code:11792-2175
Practice Address - Country:US
Practice Address - Phone:631-397-0012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF303856363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ26977Medicare UPIN
NY0766G1Medicare PIN