Provider Demographics
NPI:1568986453
Name:REED, LACEY M (PA)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:M
Last Name:REED
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2320 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-1303
Mailing Address - Country:US
Mailing Address - Phone:602-258-9900
Mailing Address - Fax:602-258-9904
Practice Address - Street 1:3367 S MERCY RD STE 210
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297-7604
Practice Address - Country:US
Practice Address - Phone:480-969-4138
Practice Address - Fax:480-969-0630
Is Sole Proprietor?:No
Enumeration Date:2017-08-01
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ6783363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZD07025791OtherDRIVERS LICENSE