Provider Demographics
NPI:1174229892
Name:GOLICK, LACEY RAE (PA)
Entity type:Individual
Prefix:
First Name:LACEY
Middle Name:RAE
Last Name:GOLICK
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 1:1430 DOVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:APEX
Mailing Address - State:NC
Mailing Address - Zip Code:27523-6429
Mailing Address - Country:US
Mailing Address - Phone:724-554-4141
Mailing Address - Fax:
Practice Address - Street 1:1430 DOVERSIDE DR
Practice Address - Street 2:
Practice Address - City:APEX
Practice Address - State:NC
Practice Address - Zip Code:27523-6429
Practice Address - Country:US
Practice Address - Phone:724-554-4141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-03
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-13085363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program