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 1:2303 S TOWNSEND AVE STE A
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81401-5452
Mailing Address - Country:US
Mailing Address - Phone:970-249-7751
Mailing Address - Fax:970-249-5029
Practice Address - Street 1:569 32 RD STE 12
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81504-6095
Practice Address - Country:US
Practice Address - Phone:970-523-3544
Practice Address - Fax:970-249-5029
Is Sole Proprietor?:No
Enumeration Date:2019-03-11
Last Update Date:2024-11-25
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