Basic Information
| Provider Information | |||||||||
| NPI: | 1679758254 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GARDNER | ||||||||
| FirstName: | LACEY | ||||||||
| MiddleName: | CAROLINE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1970 ASHLAND DR | ||||||||
| Address2: | |||||||||
| City: | MOUNT PLEASANT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488581203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897795262 | ||||||||
| FaxNumber: | 9897726784 | ||||||||
| Practice Location | |||||||||
| Address1: | 1970 ASHLAND DR | ||||||||
| Address2: | |||||||||
| City: | MOUNT PLEASANT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488581203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897795262 | ||||||||
| FaxNumber: | 9897726784 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2008 | ||||||||
| LastUpdateDate: | 02/27/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 5601005080 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 010Z960170 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER | MI1118 | 01 | MI | MEDICARE GROUP NUMBER | OTHER | 080B610040 | 01 | MI | BCBS | OTHER | 0P43930 | 01 | MI | MEDICARE GROUP NUMBER | OTHER | 0Z96017 | 01 | MI | MEDICARE GROUP | OTHER | 0Z96017 | 01 | MI | MEDICARE PTAN | OTHER |