Provider Demographics
NPI:1811290968
Name:GOLDEN, LACEY (PA)
Entity type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:GOLDEN
Suffix:
Gender:F
Credentials:PA
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 55310
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35255-5310
Mailing Address - Country:US
Mailing Address - Phone:205-731-9701
Mailing Address - Fax:
Practice Address - Street 1:48 MEDICAL PARK DR E STE 255
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35235-3464
Practice Address - Country:US
Practice Address - Phone:205-838-3090
Practice Address - Fax:205-838-3043
Is Sole Proprietor?:No
Enumeration Date:2010-12-13
Last Update Date:2019-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA.638363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL127143Medicaid
AL051114784OtherBCBS
MS04957385Medicaid
AL051114785OtherBCBS
AL127144Medicaid
AL051114787OtherBCBS
AL102I979387Medicare PIN