Basic Information
| Provider Information | |||||||||
| NPI: | 1679588750 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LILLE | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | DOUGLAS | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3141 NW 63RD | ||||||||
| Address2: | SUITE 4 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056071318 | ||||||||
| FaxNumber: | 4056071326 | ||||||||
| Practice Location | |||||||||
| Address1: | 21298 OLEAN BLVD | ||||||||
| Address2: | FAWCETT MEMORIAL HOSPITAL | ||||||||
| City: | PORT CHARLOTTE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9416276130 | ||||||||
| FaxNumber: | 9416276146 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | PA9101308 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.