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Individual
MR. LARRY P LEASE
Active
Individual
MR. LARRY P LEASE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
P.A.
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
102779
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0944PA
—
SC
01
—
164XE
BCBSNC
NC
01
—
412826953
TRICARE FOR LIFE
NC
01
—
7090171
AETNA
NC
05
—
8102485
—
NC
01
—
833406
WELLCARE OF SC
SC
01
—
970011977
RAILROAD MEDICARE
NC
01
—
98460
MEDCOST
NC
Enumeration date
03/08/2006
Last updated
03/06/2015
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