Provider Demographics
NPI:1558916114
Name:LACOMBE, MICHAEL (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:LACOMBE
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 1:2112 TARRYWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27455-2924
Mailing Address - Country:US
Mailing Address - Phone:518-727-8172
Mailing Address - Fax:
Practice Address - Street 1:104 HUFFMAN MILL RD
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215-5113
Practice Address - Country:US
Practice Address - Phone:336-506-1720
Practice Address - Fax:336-513-2136
Is Sole Proprietor?:No
Enumeration Date:2019-08-09
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024267363A00000X
GA9879363A00000X
NC0010-10515363AM0700X
363AM0700X
NC0015-10515363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical