Basic Information
| Provider Information | |||||||||
| NPI: | 1629551668 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TERAOKA | ||||||||
| FirstName: | LORI | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 MEDICAL CENTER DR | ||||||||
| Address2: | CARDIOTHORACIC SURGERY | ||||||||
| City: | LEBANON | ||||||||
| State: | NH | ||||||||
| PostalCode: | 037560001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036508537 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3181 SW SAM JACKSON PARK RD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972393011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034947820 | ||||||||
| FaxNumber: | 5034947829 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2018 | ||||||||
| LastUpdateDate: | 03/03/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 1404 | NH | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AS0400X | 196149 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 3114580 | 05 | NH | MEDICAID |