Provider Demographics
NPI:1831251586
Name:KOSTRANCHUK, LORIAN J (MD)
Entity type:Individual
Prefix:DR
First Name:LORIAN
Middle Name:J
Last Name:KOSTRANCHUK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 CARLISLE BLVD NE
Mailing Address - Street 2:SUITE B
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-5658
Mailing Address - Country:US
Mailing Address - Phone:505-232-8950
Mailing Address - Fax:
Practice Address - Street 1:1400 CARLISLE BLVD NE
Practice Address - Street 2:SUITE B
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-5658
Practice Address - Country:US
Practice Address - Phone:505-232-8950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM95-2752084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMG51588Medicare UPIN