Basic Information
| Provider Information | |||||||||
| NPI: | 1821247917 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LANDER | ||||||||
| FirstName: | LORI | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3880 NORTHWOODS CT NE | ||||||||
| Address2: | APT. 4 | ||||||||
| City: | WARREN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 444834593 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3305658386 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1301 BOARDMAN POLAND RD | ||||||||
| Address2: | |||||||||
| City: | POLAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 445141960 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306292300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2008 | ||||||||
| LastUpdateDate: | 04/30/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT-6928 | OH | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 363A00000X | MA055871 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 50.004189 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 0118900 | 05 | OH | MEDICAID |