Provider Demographics
NPI:1568448892
Name:LESTRANGE, KATHY JEAN (PAC)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:JEAN
Last Name:LESTRANGE
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:KATHY
Other - Middle Name:JEAN
Other - Last Name:LAMBERTH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 344
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27102-0344
Mailing Address - Country:US
Mailing Address - Phone:336-716-2255
Mailing Address - Fax:336-716-8190
Practice Address - Street 1:MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-0001
Practice Address - Country:US
Practice Address - Phone:336-716-2255
Practice Address - Fax:336-716-8190
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2010-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC100564363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC94710OtherMEDCOST
S85377Medicare UPIN
NC2752291AMedicare PIN