Provider Demographics
NPI:1427749639
Name:LORIAL, JEAN RENE (PA, FSA,MD)
Entity type:Individual
Prefix:DR
First Name:JEAN RENE
Middle Name:
Last Name:LORIAL
Suffix:
Gender:M
Credentials:PA, FSA,MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6211 CARD BLVD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46221-6102
Mailing Address - Country:US
Mailing Address - Phone:812-887-6081
Mailing Address - Fax:
Practice Address - Street 1:5847 S 16TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85040-3512
Practice Address - Country:US
Practice Address - Phone:602-609-4107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-17
Last Update Date:2025-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI21-263246ZC0007X
PR001660363AM0700X
FLPACN21363AM0700X
AZ10338363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical AssistantGroup - Multi-Specialty