Provider Demographics
NPI:1225586399
Name:HINSON, LACEY TAYLOR (PA)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:TAYLOR
Last Name:HINSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:2 MEDICAL PARK RD STE 300
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6839
Practice Address - Country:US
Practice Address - Phone:803-434-8800
Practice Address - Fax:803-434-8802
Is Sole Proprietor?:No
Enumeration Date:2016-09-16
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2649363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2816PAMedicaid
SCSC99525774Medicare PIN