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General NPI Number Information
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NPI Number | 1518417799
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Entity Type | Individual
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Provider Name | MIA LASSITER MEDLOCK PA-C
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Gender | Female
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Dates
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Enumeration Date | 10/11/2016
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Last Update Date | 11/23/2021
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Provider Practice Location Address
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Address Line | 838 W MEETING ST MEDICAL ARTS 5 SUITE H
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City | LANCASTER
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State | SC
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Zip | 29720
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Country | US
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Telephone | 803-286-7633
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Fax |
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Provider Business Mailing Address
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Address Line | 838 W MEETING ST MEDICAL ARTS 5 SUITE H
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City | LANCASTER
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State | SC
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Zip | 29720-6233
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 2619
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License Number State | SC
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