Healthcare Provider Details

I. General information

NPI: 1104783372
Provider Name (Legal Business Name): ANTHONY ELIJAH LOCKLEAR JR. PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2026
Last Update Date: 01/08/2026
Certification Date: 01/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

628 N 8TH ST
SMITHFIELD NC
27577
US

IV. Provider business mailing address

1408 E 11TH ST
LUMBERTON NC
28358-5000
US

V. Phone/Fax

Practice location:
  • Phone: 919-934-8171
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1217979
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: