Provider Demographics
NPI:1730182056
Name:LACEK, GREGORY A (PA-C)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:A
Last Name:LACEK
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 1:650 CHERRY TREE LN
Mailing Address - Street 2:
Mailing Address - City:UNIONTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15401-8947
Mailing Address - Country:US
Mailing Address - Phone:724-438-4364
Mailing Address - Fax:724-438-4720
Practice Address - Street 1:650 CHERRY TREE LN
Practice Address - Street 2:
Practice Address - City:UNIONTOWN
Practice Address - State:PA
Practice Address - Zip Code:15401-8947
Practice Address - Country:US
Practice Address - Phone:724-438-4364
Practice Address - Fax:724-438-4720
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2025-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA002761L363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1032536000003Medicaid
PA073586R4CMedicare ID - Type UnspecifiedPROVIDER NUMBER
PA073583Medicare ID - Type UnspecifiedGROUP NUMBER