Provider Demographics
NPI:1912125816
Name:LUP, JIM ROY (PA)
Entity Type:Individual
Prefix:
First Name:JIM
Middle Name:ROY
Last Name:LUP
Suffix:
Gender:M
Credentials:PA
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 602120
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2120
Mailing Address - Country:US
Mailing Address - Phone:704-355-2884
Mailing Address - Fax:704-355-5800
Practice Address - Street 1:1021 MOREHEAD MEDICAL DR
Practice Address - Street 2:SUITE A
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2990
Practice Address - Country:US
Practice Address - Phone:704-355-2884
Practice Address - Fax:704-355-5800
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102260363A00000X
NC0010-04274363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1659PAMedicaid
NC1912125816Medicaid
FL291498100Medicaid
FLP81262Medicare UPIN
SC1659PAMedicaid
NC1912125816Medicaid
NCNCD150BMedicare PIN
FL291498100Medicaid