Provider Demographics
NPI:1477077089
Name:WILDEBOER, LACEY JEAN (PA)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:JEAN
Last Name:WILDEBOER
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 1:7201 US HIGHWAY 64 E
Mailing Address - Street 2:
Mailing Address - City:KNIGHTDALE
Mailing Address - State:NC
Mailing Address - Zip Code:27545-9268
Mailing Address - Country:US
Mailing Address - Phone:919-266-7600
Mailing Address - Fax:
Practice Address - Street 1:7201 US HIGHWAY 64 E
Practice Address - Street 2:
Practice Address - City:KNIGHTDALE
Practice Address - State:NC
Practice Address - Zip Code:27545-9268
Practice Address - Country:US
Practice Address - Phone:919-266-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-26
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-07379363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant