Provider Demographics
NPI:1720379597
Name:MCKAY, LANCE W (PA-C)
Entity Type:Individual
Prefix:
First Name:LANCE
Middle Name:W
Last Name:MCKAY
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 1:1151 HOSPITAL WAY, BLD D
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-5091
Mailing Address - Country:US
Mailing Address - Phone:208-239-8010
Mailing Address - Fax:208-782-2974
Practice Address - Street 1:1151 HOSPITAL WAY, BLD D
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5091
Practice Address - Country:US
Practice Address - Phone:208-239-8010
Practice Address - Fax:208-782-2974
Is Sole Proprietor?:No
Enumeration Date:2011-04-27
Last Update Date:2013-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1071363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ3Z5047OtherHEALTHNET
AZ611187Medicaid
AZ611187Medicaid
AZP00937414Medicare PIN