Provider Demographics
NPI:1093467615
Name:LOTT, VICTORIA NICOLE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:VICTORIA
Middle Name:NICOLE
Last Name:LOTT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:NICOLE
Other - Last Name:BALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3215 VIRGINIA ST
Mailing Address - Street 2:
Mailing Address - City:PEARL
Mailing Address - State:MS
Mailing Address - Zip Code:39208-3535
Mailing Address - Country:US
Mailing Address - Phone:662-694-0408
Mailing Address - Fax:
Practice Address - Street 1:971 LAKELAND DR STE 656
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4608
Practice Address - Country:US
Practice Address - Phone:601-366-6606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-25
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPA00631363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant