Basic Information
Provider Information | |||||||||
NPI: | 1184806382 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | AMITRANO | ||||||||
FirstName: | LORETTA | ||||||||
MiddleName: | J. | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 12900 PARK PLAZA DR | ||||||||
Address2: | STE 150 | ||||||||
City: | CERRITOS | ||||||||
State: | CA | ||||||||
PostalCode: | 907039329 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5629774639 | ||||||||
FaxNumber: | 5267414479 | ||||||||
Practice Location | |||||||||
Address1: | 544 W UMPQUA ST | ||||||||
Address2: | SUITE 101 | ||||||||
City: | ROSEBURG | ||||||||
State: | OR | ||||||||
PostalCode: | 97471 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5416729596 | ||||||||
FaxNumber: | 5414643519 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/29/2007 | ||||||||
LastUpdateDate: | 07/18/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 111603 | AZ | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 200950086NP | OR | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | F341031 | NY | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | AP2854 | AZ | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 168395 | 05 | OR |   | MEDICAID | R103163 | 01 | OR | MEDICARE PART B | OTHER |