Basic Information
| Provider Information | |||||||||
| NPI: | 1770512618 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PRESTON | ||||||||
| FirstName: | LORI | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301C US ROUTE ONE | ||||||||
| Address2: | MAINE MEDICAL PARTNERS | ||||||||
| City: | SCARBOROUGH | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2073968600 | ||||||||
| FaxNumber: | 7404465982 | ||||||||
| Practice Location | |||||||||
| Address1: | 22 BRAMHALL STREET | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076622526 | ||||||||
| FaxNumber: | 2076626236 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2006 | ||||||||
| LastUpdateDate: | 08/08/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 50684 | WV | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 19248 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | RNA143018 | ME | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 001720720 | 01 | WV | MSBCBS | OTHER | 0069300000 | 05 | WV | MEDICAID | 2058204 | 05 | OH | MEDICAID | 001706470 | 01 | WV | MSBCBS GROUP | OTHER | 270052997003 | 01 | WV | TRICARE | OTHER | 0207026000 | 05 | WV | MEDICAID | DA0096 | 01 | WV | RR MEDICARE | OTHER | 001720720 | 01 | WV | BCBS | OTHER | 27005299700 | 01 | WV | BRICKSTREET | OTHER | 2460484 | 05 | WV | MEDICAID | 2460484 | 05 | OH | MEDICAID | 27005299700 | 01 | WV | WORKERS COMP | OTHER | P00273112 | 01 | WV | RR MEDICARE | OTHER | P00794072 | 01 | OH | RAILROAD MEDICARE | OTHER |