Provider Demographics
NPI:1295727634
Name:LUNDQUIST, ALBERT LEE (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:ALBERT
Middle Name:LEE
Last Name:LUNDQUIST
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 38157
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27438-8157
Mailing Address - Country:US
Mailing Address - Phone:336-282-5000
Mailing Address - Fax:336-545-9792
Practice Address - Street 1:3312 BATTLEGROUND AVE
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410-2402
Practice Address - Country:US
Practice Address - Phone:336-282-5000
Practice Address - Fax:336-545-9792
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2011-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC100986207W00000X
VA0110840384207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC561783008OtherTAX ID
NC561783008OtherTAX ID
NC2761642Medicare ID - Type Unspecified