Provider Demographics
NPI:1679588750
Name:LILLE, KEVIN DOUGLAS (PAC)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:DOUGLAS
Last Name:LILLE
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3141 NW 63RD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73116
Mailing Address - Country:US
Mailing Address - Phone:405-607-1318
Mailing Address - Fax:405-607-1326
Practice Address - Street 1:21298 OLEAN BLVD
Practice Address - Street 2:FAWCETT MEMORIAL HOSPITAL
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952
Practice Address - Country:US
Practice Address - Phone:941-627-6130
Practice Address - Fax:941-627-6146
Is Sole Proprietor?:No
Enumeration Date:2006-07-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101308363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
E7841Medicare ID - Type Unspecified
P64765Medicare UPIN