Provider Demographics
NPI:1881017655
Name:TUDOR, LACEY (PA)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:TUDOR
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LACEY
Other - Middle Name:
Other - Last Name:LUMPKIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:38935 ANN ARBOR RD
Mailing Address - Street 2:CREDENTIALING DEPT
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-3397
Mailing Address - Country:US
Mailing Address - Phone:734-805-0488
Mailing Address - Fax:866-250-6385
Practice Address - Street 1:8260 ATLEE RD
Practice Address - Street 2:EMERGENCY DEPT.
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23116-1844
Practice Address - Country:US
Practice Address - Phone:804-764-6300
Practice Address - Fax:804-764-6562
Is Sole Proprietor?:No
Enumeration Date:2014-01-29
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110004486363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant