Basic Information
| Provider Information | |||||||||
| NPI: | 1104313634 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LACSON | ||||||||
| FirstName: | JOHN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 33269 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850673269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024064786 | ||||||||
| FaxNumber: | 9166364358 | ||||||||
| Practice Location | |||||||||
| Address1: | 2927 N 7TH AVE | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850134102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024063153 | ||||||||
| FaxNumber: | 6024067176 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2018 | ||||||||
| LastUpdateDate: | 09/17/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 009179 | AZ | Y | Allopathic & Osteopathic Physicians | Family Medicine | 390200000X | OT18912 | PA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.