Provider Demographics
NPI:1518417799
Name:MEDLOCK, MIA LASSITER (PA-C)
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:LASSITER
Last Name:MEDLOCK
Suffix:
Gender:F
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 1:838 W MEETING ST
Mailing Address - Street 2:MEDICAL ARTS 5 SUITE H
Mailing Address - City:LANCASTER
Mailing Address - State:SC
Mailing Address - Zip Code:29720-6233
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:838 W MEETING ST
Practice Address - Street 2:MEDICAL ARTS 5 SUITE H
Practice Address - City:LANCASTER
Practice Address - State:SC
Practice Address - Zip Code:29720
Practice Address - Country:US
Practice Address - Phone:803-286-7633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-11
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2619363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2885PAMedicaid