Basic Information
| Provider Information | |||||||||
| NPI: | 1265400071 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEASE | ||||||||
| FirstName: | LARRY | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6035 FAIRVIEW RD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282103256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042953000 | ||||||||
| FaxNumber: | 7042953468 | ||||||||
| Practice Location | |||||||||
| Address1: | 6035 FAIRVIEW RD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282103256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042953000 | ||||||||
| FaxNumber: | 7042953468 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2006 | ||||||||
| LastUpdateDate: | 03/06/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 102779 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 8102485 | 05 | NC | MEDICAID | 164XE | 01 | NC | BCBSNC | OTHER | 970011977 | 01 | NC | RAILROAD MEDICARE | OTHER | 98460 | 01 | NC | MEDCOST | OTHER | 833406 | 01 | SC | WELLCARE OF SC | OTHER | 0944PA | 05 | SC | MEDICAID | 7090171 | 01 | NC | AETNA | OTHER | 412826953 | 01 | NC | TRICARE FOR LIFE | OTHER |