Provider Demographics
NPI:1417924028
Name:LACK, KEVIN (PA-C)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:LACK
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:PO BOX 3726
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30914-3726
Mailing Address - Country:US
Mailing Address - Phone:706-863-9595
Mailing Address - Fax:888-745-3917
Practice Address - Street 1:3675 J DEWEY GRAY CIRCLE
Practice Address - Street 2:SUITE 300
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-1868
Practice Address - Country:US
Practice Address - Phone:706-863-9595
Practice Address - Fax:888-745-3917
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1765363AS0400X
SCPA1198363AS0400X
TNPA0000001669363AS0400X
FLPA9106353363AS0400X
GA4292363AS0400X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA122408717AMedicaid
GAQ24393Medicare UPIN
GA97WCFVCMedicare ID - Type Unspecified