Healthcare Provider Details

I. General information

NPI: 1215767413
Provider Name (Legal Business Name): PATRICIA LACEY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2024
Last Update Date: 08/03/2024
Certification Date: 08/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3551 N BROAD ST
PHILADELPHIA PA
19140-4131
US

IV. Provider business mailing address

832 PEARL AVE
MORTON PA
19070-1243
US

V. Phone/Fax

Practice location:
  • Phone: 215-430-4000
  • Fax:
Mailing address:
  • Phone: 610-420-0362
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA065706
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: