Provider Demographics
NPI:1770033979
Name:LACEK, EMILY (PA-C)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:LACEK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:
Other - Last Name:MCGEHRIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:400 E COUNTRY CLUB LN
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:PA
Mailing Address - Zip Code:19086-6407
Mailing Address - Country:US
Mailing Address - Phone:215-480-9692
Mailing Address - Fax:
Practice Address - Street 1:1501 LANSDOWNE AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:DARBY
Practice Address - State:PA
Practice Address - Zip Code:19023-1333
Practice Address - Country:US
Practice Address - Phone:610-534-6270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-11
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA058646363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical