Provider Demographics
NPI:1356591382
Name:BRICKNER, LORI KATHRYN (PA-C)
Entity type:Individual
Prefix:MRS
First Name:LORI
Middle Name:KATHRYN
Last Name:BRICKNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:LORI
Other - Middle Name:KATHRYN
Other - Last Name:EARDLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 100
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48068-0100
Mailing Address - Country:US
Mailing Address - Phone:248-849-3137
Mailing Address - Fax:248-849-2052
Practice Address - Street 1:205 N. EAST AVE.
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201
Practice Address - Country:US
Practice Address - Phone:517-788-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-26
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005355363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601005355OtherMI STATE MEDICAL LICENSE (TEMP)