1679758254 NPI number — LACEY CAROLINE GARDNER PA-C

Table of content: LACEY CAROLINE GARDNER PA-C (NPI 1679758254)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679758254 NPI number — LACEY CAROLINE GARDNER PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GARDNER
Provider First Name:
LACEY
Provider Middle Name:
CAROLINE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679758254
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/27/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1970 ASHLAND DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNT PLEASANT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48858-1203
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-779-5262
Provider Business Mailing Address Fax Number:
989-772-6784

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1970 ASHLAND DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNT PLEASANT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48858-1203
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-779-5262
Provider Business Practice Location Address Fax Number:
989-772-6784
Provider Enumeration Date:
01/02/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  5601005080 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 010Z960170 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: MI1118 . This is a "MEDICARE GROUP NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 080B610040 . This is a "BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0P43930 . This is a "MEDICARE GROUP NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0Z96017 . This is a "MEDICARE GROUP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0Z96017 . This is a "MEDICARE PTAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com