Provider Demographics
NPI: | 1669443727 |
---|---|
Name: | KACAL, MICHAEL JOHN (PA-C) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | MICHAEL |
Middle Name: | JOHN |
Last Name: | KACAL |
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: | 6001 34TH ST SPC 164 |
Mailing Address - Street 2: | |
Mailing Address - City: | LUBBOCK |
Mailing Address - State: | TX |
Mailing Address - Zip Code: | 79407-3106 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 817-219-0148 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 6001 34TH ST SPC 164 |
Practice Address - Street 2: | |
Practice Address - City: | LUBBOCK |
Practice Address - State: | TX |
Practice Address - Zip Code: | 79407-3106 |
Practice Address - Country: | US |
Practice Address - Phone: | 817-219-0148 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-01-27 |
Last Update Date: | 2024-02-15 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
TX | PA03371 | 363AM0700X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363AM0700X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
TX | 9B847A | Other | HEALTHSMART PPO |
TX | 2242884 | Other | UNITEDHEALTHCARE |
TX | P00137141 | Other | MEDICARE RAILROAD |
TX | 8N4110 | Other | BC/BS |
TX | P60305 | Medicare UPIN | |
TX | 8N4110 | Other | BC/BS |