Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 006806 | AZ |
N | 207Q00000X | Family Doctor | 5315064402 | MI |
NPI | 1003161035 |
---|---|
Provider Name | Michael James Lacaze |
First Address | Prescott, AZ 86304-0880 |
Second Address | Prescott, AZ 86305-1640 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/07/2012 |
Last Update Date | 09/05/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
006806 | AZ LICENSE (01) | AZ |
1003161035 | (05) | MI |
Z192483 | (05) | AZ |