Provider Demographics
NPI:1265400071
Name:LEASE, LARRY P (PA)
Entity type:Individual
Prefix:MR
First Name:LARRY
Middle Name:P
Last Name:LEASE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:6035 FAIRVIEW RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-3256
Mailing Address - Country:US
Mailing Address - Phone:704-295-3000
Mailing Address - Fax:704-295-3468
Practice Address - Street 1:6035 FAIRVIEW RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-3256
Practice Address - Country:US
Practice Address - Phone:704-295-3000
Practice Address - Fax:704-295-3468
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2015-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102779363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8102485Medicaid
NC164XEOtherBCBSNC
NC970011977OtherRAILROAD MEDICARE
NC98460OtherMEDCOST
SC833406OtherWELLCARE OF SC
SC0944PAMedicaid
NC7090171OtherAETNA
NC412826953OtherTRICARE FOR LIFE
P06541Medicare UPIN
NC412826953OtherTRICARE FOR LIFE