Provider Demographics
NPI:1649283458
Name:SUMNER, LORI AGAN (PA)
Entity type:Individual
Prefix:MRS
First Name:LORI
Middle Name:AGAN
Last Name:SUMNER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 604050
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-4050
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9930 KINCEY AVE STE 130
Practice Address - Street 2:
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-6541
Practice Address - Country:US
Practice Address - Phone:980-556-7140
Practice Address - Fax:704-917-4147
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101622363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S62994Medicare UPIN
2747699CMedicare ID - Type Unspecified