Basic Information
| Provider Information | |||||||||
| NPI: | 1801123989 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CROCKER | ||||||||
| FirstName: | LACEY | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | P.A. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SIRDENIS | ||||||||
| OtherFirstName: | LACEY | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1847 | ||||||||
| Address2: | |||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494431847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317275211 | ||||||||
| FaxNumber: | 2317274571 | ||||||||
| Practice Location | |||||||||
| Address1: | 6401 PRAIRIE ST STE 1700 | ||||||||
| Address2: | |||||||||
| City: | NORTON SHORES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494447843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317277944 | ||||||||
| FaxNumber: | 2317247812 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2009 | ||||||||
| LastUpdateDate: | 06/27/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 5601005668 | MI | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X | 5601005668 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | MI1763124 | 01 | MI | CMS MEDICARE | OTHER |