Provider Demographics
NPI:1144650201
Name:LACSON, PHILIP (PA-C)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:
Last Name:LACSON
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 1:18100 NE 19TH AVE
Mailing Address - Street 2:#102
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33162-1606
Mailing Address - Country:US
Mailing Address - Phone:305-949-6003
Mailing Address - Fax:305-948-3911
Practice Address - Street 1:18100 NE 19TH AVE
Practice Address - Street 2:#102
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33162-1606
Practice Address - Country:US
Practice Address - Phone:305-949-6003
Practice Address - Fax:305-948-3911
Is Sole Proprietor?:No
Enumeration Date:2013-11-26
Last Update Date:2015-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9107668363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant