Basic Information
| Provider Information | |||||||||
| NPI: | 1588735104 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MITCHELL | ||||||||
| FirstName: | KORY | ||||||||
| MiddleName: | LANCE | ||||||||
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| Credential: | ACUTE CARE NURSE PRA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5219 CITY BANK PKWY STE 35 | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 79407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067610333 | ||||||||
| FaxNumber: | 8067820097 | ||||||||
| Practice Location | |||||||||
| Address1: | 3502 9TH ST STE 260 | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794155305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067928185 | ||||||||
| FaxNumber: | 8067929180 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2006 | ||||||||
| LastUpdateDate: | 08/29/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WM0705X | 663921 | TX | N | Nursing Service Providers | Registered Nurse | Medical-Surgical | 363LA2100X | AP114881 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | 8Y1753 | 01 | TX | BCBS OF TEXAS | OTHER | 45939268 | 05 | NM | MEDICAID | 8Y5044 | 01 | TX | BCBS OF TEXAS | OTHER | 151566101 | 01 | FIRSTCARE | OTHER |