Provider Demographics
NPI:1043573066
Name:LAZORKA, JEREMY DANIEL (PA-C)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:DANIEL
Last Name:LAZORKA
Suffix:
Gender:M
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 1:45 BELLEFONTE AVE
Mailing Address - Street 2:SUITE #2
Mailing Address - City:LOCK HAVEN
Mailing Address - State:PA
Mailing Address - Zip Code:17745-1237
Mailing Address - Country:US
Mailing Address - Phone:570-858-5328
Mailing Address - Fax:570-858-5355
Practice Address - Street 1:45 BELLEFONTE AVE
Practice Address - Street 2:SUITE #2
Practice Address - City:LOCK HAVEN
Practice Address - State:PA
Practice Address - Zip Code:17745
Practice Address - Country:US
Practice Address - Phone:570-858-5328
Practice Address - Fax:570-858-5355
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-25
Last Update Date:2024-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA055552363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA6Z2639OtherMEDICARE PTAN
PA103271986-0004Medicaid