Basic Information
| Provider Information | |||||||||
| NPI: | 1194072140 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ST JOHN | ||||||||
| FirstName: | LORI | ||||||||
| MiddleName: | |||||||||
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| OtherLastName: | GOUGH | ||||||||
| OtherFirstName: | LORI | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 525 E 68TH ST | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100654870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2127465454 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 525 E 68TH ST | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100654870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2127465454 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2012 | ||||||||
| LastUpdateDate: | 03/18/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 015846 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.