Provider Demographics
NPI:1114956604
Name:LANCASTER, KEVIN P (PA-C)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:P
Last Name:LANCASTER
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 1:4601 PARK RD
Mailing Address - Street 2:STE. 300
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-3239
Mailing Address - Country:US
Mailing Address - Phone:704-323-2000
Mailing Address - Fax:
Practice Address - Street 1:10496 KATY FWY
Practice Address - Street 2:#101
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77043-5106
Practice Address - Country:US
Practice Address - Phone:346-571-7500
Practice Address - Fax:713-492-2440
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04768363AM0700X, 363AS0400X
TX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX362152601Medicaid
TX510804ZU13Medicare PIN