Basic Information
| Provider Information | |||||||||
| NPI: | 1578900890 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SANDERSON | ||||||||
| FirstName: | LACIE | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 118 WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | HARRISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 171041677 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 111 S FRONT ST | ||||||||
| Address2: | |||||||||
| City: | HARRISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 171012010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177823380 | ||||||||
| FaxNumber: | 7177825716 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2013 | ||||||||
| LastUpdateDate: | 05/28/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.