Provider Demographics
NPI:1730489311
Name:LASOSKI, JACK CHAIM (PA-C)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:CHAIM
Last Name:LASOSKI
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 1:5600 HOBBS RD
Mailing Address - Street 2:
Mailing Address - City:KEVIL
Mailing Address - State:KY
Mailing Address - Zip Code:42053-9685
Mailing Address - Country:US
Mailing Address - Phone:270-441-6266
Mailing Address - Fax:270-441-6208
Practice Address - Street 1:5600 HOBBS RD
Practice Address - Street 2:
Practice Address - City:KEVIL
Practice Address - State:KY
Practice Address - Zip Code:42053-9685
Practice Address - Country:US
Practice Address - Phone:270-441-6266
Practice Address - Fax:270-441-6208
Is Sole Proprietor?:No
Enumeration Date:2010-10-28
Last Update Date:2010-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA020363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant