Provider Demographics
NPI:1043790983
Name:LAKESIDE PRIMARY CARE, PSC
Entity Type:Organization
Organization Name:LAKESIDE PRIMARY CARE, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:APRN/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:THURESA
Authorized Official - Middle Name:S
Authorized Official - Last Name:CASH
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:606-341-1339
Mailing Address - Street 1:PO BOX 85
Mailing Address - Street 2:
Mailing Address - City:BURNSIDE
Mailing Address - State:KY
Mailing Address - Zip Code:42519
Mailing Address - Country:US
Mailing Address - Phone:606-310-2640
Mailing Address - Fax:
Practice Address - Street 1:6470 S HWY 27
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42501
Practice Address - Country:US
Practice Address - Phone:606-341-1339
Practice Address - Fax:606-341-1340
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-20
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty