Basic Information
| Provider Information | |||||||||
| NPI: | 1629161427 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANTICO | ||||||||
| FirstName: | LORRAINE | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | APN C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LAPUZZ-DURKIN | ||||||||
| OtherFirstName: | LORRAINE | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1 FEDERAL ST # 200 | ||||||||
| Address2: | |||||||||
| City: | CAMDEN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 081031088 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8563564924 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | ONE COOPER PLAZA | ||||||||
| Address2: | COOPER UNIVERSITY TRAUMA PHYSICIANS | ||||||||
| City: | CAMDEN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 08103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8563423014 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 10/18/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | SP001886C | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | NN05816800 | NJ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | NN05816800 | 01 | NJ | STATE | OTHER |