Provider Demographics
NPI:1356395818
Name:MOCK-BLAIR, LORI D (PA-C)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:D
Last Name:MOCK-BLAIR
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:D
Other - Last Name:MOCK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:5002 COWHORN CREEK RD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-9766
Mailing Address - Country:US
Mailing Address - Phone:903-614-3000
Mailing Address - Fax:903-614-3525
Practice Address - Street 1:5002 COWHORN CREEK RD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-9766
Practice Address - Country:US
Practice Address - Phone:903-614-3000
Practice Address - Fax:903-614-3525
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03107363A00000X
LAPA200543363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX482007ZTZ8Medicare PIN