Provider Demographics
NPI:1174567374
Name:STUPP-BOBULA, LORI (PA-C)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:STUPP-BOBULA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 VINE ST
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45220-2213
Mailing Address - Country:US
Mailing Address - Phone:513-475-6509
Mailing Address - Fax:
Practice Address - Street 1:3200 VINE ST
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45220-2213
Practice Address - Country:US
Practice Address - Phone:513-475-6509
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9109437363A00000X
NJ25MP00071900363A00000X, 363A00000X
KYPA 1739363A00000X
IL085004287363A00000X
OH50.003029363A00000X
NY004787363A00000X
NY4787-01363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P27172Medicare UPIN
NJ052485Medicare ID - Type Unspecified