Provider Demographics
NPI:1255340683
Name:INDENBAUM, LORI B (PA-C)
Entity type:Individual
Prefix:MS
First Name:LORI
Middle Name:B
Last Name:INDENBAUM
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 1:2101 E JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-2414
Mailing Address - Fax:301-388-1740
Practice Address - Street 1:2101 E JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20852-4908
Practice Address - Country:US
Practice Address - Phone:301-816-2414
Practice Address - Fax:301-388-1740
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC01810363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDH330769WMedicare PIN