Provider Demographics
NPI:1972552529
Name:KIRBY, LANCE A (PA-C)
Entity Type:Individual
Prefix:MR
First Name:LANCE
Middle Name:A
Last Name:KIRBY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:35318 EAGLE WAY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60678-1353
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:3700 W 203RD ST STE 301
Practice Address - Street 2:
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461-1182
Practice Address - Country:US
Practice Address - Phone:708-679-2850
Practice Address - Fax:708-503-3816
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085000829363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL5686066OtherMEDICARE PTAN
P12009Medicare UPIN