Basic Information
| Provider Information | |||||||||
| NPI: | 1275793804 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LACEY | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | ANTHONY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 820 N CHELAN AVE | ||||||||
| Address2: | |||||||||
| City: | WENATCHEE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988012028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5096638711 | ||||||||
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| Practice Location | |||||||||
| Address1: | 17 S WESTERN AVE | ||||||||
| Address2: | |||||||||
| City: | TONASKET | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988559270 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094862174 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2008 | ||||||||
| LastUpdateDate: | 06/28/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MR-0981 | ID | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD60222862 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0284414 | 01 | WA | L&I | OTHER | MR-0981 | 01 | ID | BOARD OF MEDICINE | OTHER | 1275793804 | 05 | WA | MEDICAID |