Provider Demographics
NPI:1275793804
Name:LACEY, PAUL ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:ANTHONY
Last Name:LACEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 N CHELAN AVE
Mailing Address - Street 2:
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98801-2028
Mailing Address - Country:US
Mailing Address - Phone:509-663-8711
Mailing Address - Fax:
Practice Address - Street 1:17 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:TONASKET
Practice Address - State:WA
Practice Address - Zip Code:98855-9270
Practice Address - Country:US
Practice Address - Phone:509-486-2174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-17
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMR-0981207Q00000X
WAMD60222862207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0284414OtherL&I
IDMR-0981OtherBOARD OF MEDICINE
WA1275793804Medicaid
WAG8902563Medicare PIN
WA1275793804Medicaid