Basic Information
| Provider Information | |||||||||
| NPI: | 1255309076 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ECKERSTORFER | ||||||||
| FirstName: | LORI | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 40 | ||||||||
| Address2: | |||||||||
| City: | CARIBOU | ||||||||
| State: | ME | ||||||||
| PostalCode: | 047360040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2074982359 | ||||||||
| FaxNumber: | 2074983947 | ||||||||
| Practice Location | |||||||||
| Address1: | 163 VAN BUREN RD | ||||||||
| Address2: | |||||||||
| City: | CARIBOU | ||||||||
| State: | ME | ||||||||
| PostalCode: | 047363567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2074923451 | ||||||||
| FaxNumber: | 2074981392 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2006 | ||||||||
| LastUpdateDate: | 09/19/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA309 | ME | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 12016304 | 01 | CAQH | OTHER |