Provider Demographics
NPI:1790210532
Name:LACZKO, COURTNEY N (PA-C)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:N
Last Name:LACZKO
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 1:3588 SEQUOIA DR
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45431-3779
Mailing Address - Country:US
Mailing Address - Phone:518-956-0372
Mailing Address - Fax:
Practice Address - Street 1:3535 PENTAGON BLVD
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45431-1705
Practice Address - Country:US
Practice Address - Phone:937-702-4503
Practice Address - Fax:937-702-4129
Is Sole Proprietor?:No
Enumeration Date:2017-05-01
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA059099363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant