Provider Demographics
NPI:1588735104
Name:MITCHELL, KORY LANCE (ACUTE CARE NURSE PRA)
Entity type:Individual
Prefix:
First Name:KORY
Middle Name:LANCE
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:ACUTE CARE NURSE PRA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5219 CITY BANK PKWY STE 35
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79407
Mailing Address - Country:US
Mailing Address - Phone:806-761-0333
Mailing Address - Fax:806-782-0097
Practice Address - Street 1:3502 9TH ST STE 260
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79415-5305
Practice Address - Country:US
Practice Address - Phone:806-792-8185
Practice Address - Fax:806-792-9180
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX663921163WM0705X, 163WM0705X
TXAP114881363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8Y1753OtherBCBS OF TEXAS
NM45939268Medicaid
TX8Y5044OtherBCBS OF TEXAS
151566101OtherFIRSTCARE
TX8Y1753OtherBCBS OF TEXAS
TXP00424057Medicare PIN