Provider Demographics
NPI:1417360462
Name:LUPP, THOMAS II
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:LUPP
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4125 LONGVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16510-3535
Mailing Address - Country:US
Mailing Address - Phone:814-860-0777
Mailing Address - Fax:
Practice Address - Street 1:4125 LONGVIEW AVE
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16510-3535
Practice Address - Country:US
Practice Address - Phone:814-860-0777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-07
Last Update Date:2014-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
291900000X
HI4830291U00000X
1108070014291U00000X
44317291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
No291900000XLaboratoriesMilitary Clinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI4830OtherSTATE OF HAWAII MLT
1108070014OtherUS DEPT OF HHS - CLINICAL LABORATORY TECHNOLOGIST
44317OtherASCP MLT
44317OtherASCP MLT