Provider Demographics
NPI:1780910547
Name:LACEFIELD, SCOTT (PA-C)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:LACEFIELD
Suffix:
Gender:M
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 1:6640 KANIKSU ST
Mailing Address - Street 2:
Mailing Address - City:BONNERS FERRY
Mailing Address - State:ID
Mailing Address - Zip Code:83805-7532
Mailing Address - Country:US
Mailing Address - Phone:208-267-3141
Mailing Address - Fax:209-267-0660
Practice Address - Street 1:6641 KANIKSU ST
Practice Address - Street 2:SUITE A
Practice Address - City:BONNERS FERRY
Practice Address - State:ID
Practice Address - Zip Code:83805-7532
Practice Address - Country:US
Practice Address - Phone:208-267-3655
Practice Address - Fax:208-267-3757
Is Sole Proprietor?:No
Enumeration Date:2009-10-28
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT594363A00000X
IDPA-1184363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant