Provider Demographics
NPI:1578900890
Name:SANDERSON, LACIE LYNANN (PA-C)
Entity type:Individual
Prefix:
First Name:LACIE
Middle Name:LYNANN
Last Name:SANDERSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LACIE
Other - Middle Name:LYNANN
Other - Last Name:SNYDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7 DOCK HILL RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17842-8910
Mailing Address - Country:US
Mailing Address - Phone:570-837-2123
Mailing Address - Fax:570-837-2185
Practice Address - Street 1:52 RED HILL CT
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:PA
Practice Address - Zip Code:17074-8706
Practice Address - Country:US
Practice Address - Phone:717-567-3151
Practice Address - Fax:717-567-7571
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-28
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA056200363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1031860430001Medicaid