Basic Information
Provider Information
NPI: 1003150186
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: COLE
FirstName: KEVIN
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 3502 9TH ST
Address2: SUITE 430
City: LUBBOCK
State: TX
PostalCode: 794153300
CountryCode: US
TelephoneNumber: 8067441171
FaxNumber:  
Practice Location
Address1: 3502 9TH ST
Address2: SUITE 430
City: LUBBOCK
State: TX
PostalCode: 794153300
CountryCode: US
TelephoneNumber: 8067441171
FaxNumber:  
Other Information
ProviderEnumerationDate: 11/15/2012
LastUpdateDate: 11/15/2012
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363LF0000X761618TXY Physician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily

No ID Information.


Home