Provider Demographics
NPI:1881971927
Name:BRACKBILL, LORI NICOLE (PA-C)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:NICOLE
Last Name:BRACKBILL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2104 HARRISBURG PIKE STE 200
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17601-2644
Mailing Address - Country:US
Mailing Address - Phone:717-544-3626
Mailing Address - Fax:717-544-3628
Practice Address - Street 1:2104 HARRISBURG PIKE STE 200
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17601-2644
Practice Address - Country:US
Practice Address - Phone:717-544-3626
Practice Address - Fax:717-544-3628
Is Sole Proprietor?:No
Enumeration Date:2011-11-03
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA055163363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1032013000003Medicaid
PA1603241OtherGATEWAY MEDICARE ASSURED
PA2678804OtherHIGHMARK BLUE SHIELD - FREEDOM BLUE
PAP01030644Medicare PIN