Provider Demographics
NPI:1619495454
Name:FATER, LACEY (PA-C)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:FATER
Suffix:
Gender:F
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 1:245 OLD COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-2726
Mailing Address - Country:US
Mailing Address - Phone:631-465-6141
Mailing Address - Fax:631-465-1967
Practice Address - Street 1:207 GLEN COVE AVE
Practice Address - Street 2:
Practice Address - City:SEA CLIFF
Practice Address - State:NY
Practice Address - Zip Code:11579-1455
Practice Address - Country:US
Practice Address - Phone:516-676-1742
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-31
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant