Provider Demographics
NPI:1922566744
Name:BAKER, LACEY J (PA-C)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:J
Last Name:BAKER
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 1:2454 HWY 6 AND 50 STE 104
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81505-1117
Mailing Address - Country:US
Mailing Address - Phone:435-459-0422
Mailing Address - Fax:
Practice Address - Street 1:2454 HWY 6 AND 50 STE 104
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81505-1117
Practice Address - Country:US
Practice Address - Phone:970-644-9900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-11
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0007059363A00000X
CA58746363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO15-097-0633OtherDRIVER'S LICENSE