Provider Demographics
NPI:1629551668
Name:TERAOKA, LORI M (PA)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:M
Last Name:TERAOKA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MEDICAL CENTER DR
Mailing Address - Street 2:CARDIOTHORACIC SURGERY
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03756-0001
Mailing Address - Country:US
Mailing Address - Phone:603-650-8537
Mailing Address - Fax:
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3011
Practice Address - Country:US
Practice Address - Phone:503-494-7820
Practice Address - Fax:503-494-7829
Is Sole Proprietor?:No
Enumeration Date:2018-09-14
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1404363AS0400X
OR196149363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3114580Medicaid