MEDICARE: LACEY MAY CARPENTER P.A.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	363AM0700X	Medical Physician Assistant	PA60097518	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1639306749
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LACEY MAY CARPENTER P.A.C.

Provider Business Mailing Address
First Line	:	17742 BEACH BLVD STE 240
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92647-6835
Country	:	US
Telephone Number	:	714-842-0444
Fax Number	:	714-842-8444

Provider Business Practice Location Address
First Line	:	17742 BEACH BLVD STE 240
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92647-6835
Country	:	US
Telephone Number	:	714-842-0444
Fax Number	:	714-842-8444

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

Provider Enumeration Date	:	06/16/2009
Last Update Date	:	09/28/2021

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