Healthcare Provider Details

I. General information

NPI: 1619495454
Provider Name (Legal Business Name): LACEY FATER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 GLEN COVE AVE
SEA CLIFF NY
11579-1455
US

IV. Provider business mailing address

245 OLD COUNTRY RD
MELVILLE NY
11747-2726
US

V. Phone/Fax

Practice location:
  • Phone: 516-676-1742
  • Fax:
Mailing address:
  • Phone: 631-465-6141
  • Fax: 631-465-1967

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: