Provider Demographics
NPI:1912542911
Name:LACAYO, MICHELLE JEANINE (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:JEANINE
Last Name:LACAYO
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 1:1234 HUFFMAN MILL RD
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27215-8777
Mailing Address - Country:US
Mailing Address - Phone:619-405-5897
Mailing Address - Fax:
Practice Address - Street 1:1234 HUFFMAN MILL RD
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215-8777
Practice Address - Country:US
Practice Address - Phone:619-405-5897
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-13
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-09490363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant