Basic Information
Provider Information | |||||||||
NPI: | 1881017655 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TUDOR | ||||||||
FirstName: | LACEY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LUMPKIN | ||||||||
OtherFirstName: | LACEY | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 38935 ANN ARBOR RD | ||||||||
Address2: | CREDENTIALING DEPT | ||||||||
City: | LIVONIA | ||||||||
State: | MI | ||||||||
PostalCode: | 481503397 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7348050488 | ||||||||
FaxNumber: | 8662506385 | ||||||||
Practice Location | |||||||||
Address1: | 8260 ATLEE RD | ||||||||
Address2: | EMERGENCY DEPT. | ||||||||
City: | MECHANICSVILLE | ||||||||
State: | VA | ||||||||
PostalCode: | 231161844 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8047646300 | ||||||||
FaxNumber: | 8047646562 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/29/2014 | ||||||||
LastUpdateDate: | 01/29/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0110004486 | VA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.