Provider Demographics
NPI:1497361752
Name:LACOLLA, GINA MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:MARIE
Last Name:LACOLLA
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 1:523 MEADOWDALE ST
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48220-2446
Mailing Address - Country:US
Mailing Address - Phone:586-744-6794
Mailing Address - Fax:
Practice Address - Street 1:1255 N OAKLAND BLVD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48327-1545
Practice Address - Country:US
Practice Address - Phone:248-599-8999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-21
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601010201363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant