Provider Demographics
NPI:1710969597
Name:LORELLO, MICHAEL R (PA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:LORELLO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 W BAY DR STE 232
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33770-3269
Mailing Address - Country:US
Mailing Address - Phone:727-316-5033
Mailing Address - Fax:727-316-5033
Practice Address - Street 1:801 W BAY DR STE 232
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33770-3269
Practice Address - Country:US
Practice Address - Phone:727-316-5033
Practice Address - Fax:727-316-5033
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-16
Last Update Date:2025-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00052700363A00000X
FLPA9101788363A00000X
PAMA002676L363A00000X
DEC5-0012026363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291311900Medicaid