Provider Demographics
NPI:1568537579
Name:COLSON, LACY ALSTON (MD)
Entity Type:Individual
Prefix:MS
First Name:LACY
Middle Name:ALSTON
Last Name:COLSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 SUNNYBROOK RD STE 120
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610
Mailing Address - Country:US
Mailing Address - Phone:919-231-6073
Mailing Address - Fax:919-231-8093
Practice Address - Street 1:123 SUNNYBROOK RD STE 120
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610
Practice Address - Country:US
Practice Address - Phone:919-231-6073
Practice Address - Fax:919-231-8093
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC18360207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8923811Medicaid
23811OtherBC BS
C81471Medicare UPIN
202766Medicare ID - Type Unspecified
23811OtherBC BS