Healthcare Provider Details

I. General information

NPI: 1144568080
Provider Name (Legal Business Name): LACEY MARIE KANE P.A.-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2013
Last Update Date: 03/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

718 N MACOMB ST
MONROE MI
48162-7815
US

IV. Provider business mailing address

1 SEAGATE STE 800
TOLEDO OH
43604-1558
US

V. Phone/Fax

Practice location:
  • Phone: 734-240-8927
  • Fax: 734-240-8987
Mailing address:
  • Phone: 567-585-1918
  • Fax: 419-824-7359

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601006595
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: