Provider Demographics
NPI:1063801793
Name:LAZECKO, EILEEN (PA-C)
Entity type:Individual
Prefix:
First Name:EILEEN
Middle Name:
Last Name:LAZECKO
Suffix:
Gender:F
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 1:527 COMMONS WAY
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28409-9189
Mailing Address - Country:US
Mailing Address - Phone:815-715-3733
Mailing Address - Fax:
Practice Address - Street 1:2800 ASHTON DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28412-2575
Practice Address - Country:US
Practice Address - Phone:910-794-8895
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-19
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-05397363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1063801793Medicaid