=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215767413
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PATRICIA LACEY PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/03/2024
-----------------------------------------------------
Last Update Date | 08/03/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3551 N BROAD ST
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19140-4131
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-430-4000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 832 PEARL AVE
-----------------------------------------------------
City | MORTON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19070-1243
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-420-0362
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | MA065706
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------