Provider Demographics
NPI:1578693040
Name:LACE, MICHAEL ROGER (PA)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ROGER
Last Name:LACE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:49 IROQUOIS DR
Mailing Address - Street 2:
Mailing Address - City:BRIGHTWATERS
Mailing Address - State:NY
Mailing Address - Zip Code:11718-1210
Mailing Address - Country:US
Mailing Address - Phone:516-380-7088
Mailing Address - Fax:
Practice Address - Street 1:111 E 210TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-2401
Practice Address - Country:US
Practice Address - Phone:718-920-5795
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009906363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant