Provider Demographics
NPI:1164709630
Name:WILKINSON, LACEE (PA-C)
Entity Type:Individual
Prefix:
First Name:LACEE
Middle Name:
Last Name:WILKINSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3550 N UNIVERSITY AVE STE 250
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-6695
Mailing Address - Country:US
Mailing Address - Phone:801-374-9625
Mailing Address - Fax:801-374-9690
Practice Address - Street 1:3550 N UNIVERSITY AVE STE 250
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604
Practice Address - Country:US
Practice Address - Phone:801-374-9625
Practice Address - Fax:801-374-9690
Is Sole Proprietor?:No
Enumeration Date:2011-11-10
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA52245363AM0700X, 363AS0400X
UT8139778-1206363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical