Provider Demographics
NPI:1558759555
Name:LAGOMARCINO, JACOB (PA-C)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:LAGOMARCINO
Suffix:
Gender:M
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 1:450 S EAST ST
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27601-2054
Mailing Address - Country:US
Mailing Address - Phone:630-649-0035
Mailing Address - Fax:
Practice Address - Street 1:935 SHOTWELL RD
Practice Address - Street 2:SUITE 108
Practice Address - City:CLAYTON
Practice Address - State:NC
Practice Address - Zip Code:27520-5597
Practice Address - Country:US
Practice Address - Phone:919-550-0821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-30
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-05433363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant