Provider Demographics
NPI:1790226504
Name:GARDNER, LACEY (PA-C)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:GARDNER
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:PO BOX 732
Mailing Address - Street 2:
Mailing Address - City:ANTLERS
Mailing Address - State:OK
Mailing Address - Zip Code:74523-0732
Mailing Address - Country:US
Mailing Address - Phone:580-579-3314
Mailing Address - Fax:
Practice Address - Street 1:865 DESHONG DR
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:TX
Practice Address - Zip Code:75460-9313
Practice Address - Country:US
Practice Address - Phone:903-785-4521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-13
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA11191363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0000000Medicaid