Provider Demographics
NPI:1376643379
Name:LACE, RONALD E (PA)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:E
Last Name:LACE
Suffix:
Gender:M
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:PO BOX 917156
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-7156
Mailing Address - Country:US
Mailing Address - Phone:407-292-0039
Mailing Address - Fax:904-346-0113
Practice Address - Street 1:10000 W COLONIAL DR
Practice Address - Street 2:
Practice Address - City:OCOEE
Practice Address - State:FL
Practice Address - Zip Code:34761-3498
Practice Address - Country:US
Practice Address - Phone:407-296-1000
Practice Address - Fax:904-346-0113
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA0002270363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLS60620Medicare UPIN
FLE1086YMedicare ID - Type Unspecified