MEDICARE: PHILIP LACSON PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA 9107668	FL
2	363AM0700X	Medical Physician Assistant	PA 9107668	FL

General Provider Information

NPI Number	:	1144650201
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHILIP LACSON PA-C

Provider Business Mailing Address
First Line	:	18100 NE 19TH AVE
Second Line	:	#102
City	:	NORTH MIAMI BEACH
State	:	FL
Zip	:	33162-1606
Country	:	US
Telephone Number	:	305-949-6003
Fax Number	:	305-948-3911

Provider Business Practice Location Address
First Line	:	18100 NE 19TH AVE
Second Line	:	#102
City	:	NORTH MIAMI BEACH
State	:	FL
Zip	:	33162-1606
Country	:	US
Telephone Number	:	305-949-6003
Fax Number	:	305-948-3911

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/26/2013
Last Update Date	:	04/12/2015

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Directions to “ PHILIP LACSON PA-C” Practice Location

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