Provider Demographics
NPI:1003828575
Name:LOCK, KELLY (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:LOCK
Suffix:
Gender:F
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 1:1220 HILLSIDE LN
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:TX
Mailing Address - Zip Code:77657-9056
Mailing Address - Country:US
Mailing Address - Phone:409-755-0980
Mailing Address - Fax:
Practice Address - Street 1:6450 FOLSOM DR
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77706-7269
Practice Address - Country:US
Practice Address - Phone:409-835-0524
Practice Address - Fax:409-835-0632
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04685363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S93547Medicare UPIN