Provider Demographics
NPI:1679622104
Name:LOVENBERG, RICHARD MCKAY (PA-C)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:MCKAY
Last Name:LOVENBERG
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1207 HIGHLAND DR
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27889-3405
Mailing Address - Country:US
Mailing Address - Phone:252-946-6515
Mailing Address - Fax:
Practice Address - Street 1:1207 HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:NC
Practice Address - Zip Code:27889-3405
Practice Address - Country:US
Practice Address - Phone:252-946-6515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102306363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2743932Medicare ID - Type UnspecifiedMEDICARE PROVIDER
NCS39795Medicare UPIN