Provider Demographics
NPI:1518981927
Name:LAKE, KENNETH DOUGLAS (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:DOUGLAS
Last Name:LAKE
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 2005
Mailing Address - Street 2:
Mailing Address - City:ASHEBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27204-2005
Mailing Address - Country:US
Mailing Address - Phone:336-625-1172
Mailing Address - Fax:336-625-6434
Practice Address - Street 1:300 MACK RD
Practice Address - Street 2:
Practice Address - City:ASHEBORO
Practice Address - State:NC
Practice Address - Zip Code:27205-1066
Practice Address - Country:US
Practice Address - Phone:336-625-1172
Practice Address - Fax:336-625-6434
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101208363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1582KOtherBCBS NC
NC1518981927Medicaid
R40040Medicare UPIN