Provider Demographics
NPI:1831923101
Name:GOLDSTEIN, LACY (PA-C)
Entity type:Individual
Prefix:
First Name:LACY
Middle Name:
Last Name:GOLDSTEIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LACY
Other - Middle Name:
Other - Last Name:GILLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:913 N DIXIE AVE
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-2503
Mailing Address - Country:US
Mailing Address - Phone:270-706-1212
Mailing Address - Fax:
Practice Address - Street 1:913 N DIXIE AVE
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2503
Practice Address - Country:US
Practice Address - Phone:270-706-1212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-29
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTC001363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant