Provider Demographics
NPI:1679758254
Name:GARDNER, LACEY CAROLINE (PA-C)
Entity type:Individual
Prefix:
First Name:LACEY
Middle Name:CAROLINE
Last Name:GARDNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1970 ASHLAND DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-1203
Mailing Address - Country:US
Mailing Address - Phone:989-779-5262
Mailing Address - Fax:989-772-6784
Practice Address - Street 1:1970 ASHLAND DR
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-1203
Practice Address - Country:US
Practice Address - Phone:989-779-5262
Practice Address - Fax:989-772-6784
Is Sole Proprietor?:No
Enumeration Date:2008-01-02
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005080363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI010Z960170OtherBLUE CROSS BLUE SHIELD
MIMI1118OtherMEDICARE GROUP NUMBER
MI080B610040OtherBCBS
MI0P43930OtherMEDICARE GROUP NUMBER
MI0Z96017OtherMEDICARE GROUP
MI0Z96017OtherMEDICARE PTAN
MIZ96017093Medicare PIN
MIMI1118002Medicare PIN
MI0P43930OtherMEDICARE GROUP NUMBER