Lacey L Jandrin, PA-C
Individual provider Active NPI Physician Assistant · Green Bay, WI
NPI 1104183516 · NPPES record last updated Jan 30, 2023
Key facts
- NPI
- 1104183516
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Physician Assistant 363A00000X
- License
- 3761-23 (WI)
- Practice address
- 1970 S Ridge Rd
Green Bay, WI 54304-4125 - Phone
- (920) 430-4888
- Fax
- (920) 430-4889
- NPI assigned
- Apr 23, 2012
- Sex
- Female
- Sole proprietor
- No
Organizations & group practices 13
Medicare Care Compare profile
- Specialty
- Physician Assistant
- Education
- University of North Dakota School of Medicine, 2016
- Medicare assignment
- Accepts the Medicare-approved amount as payment in full
- Group practices
- Bellin Memorial Hospital Inc
Practice addresses (Care Compare)
1970 S Ridge Rd
Green Bay, WI 54304-4125
Phone (920) 430-4888
2020 S Webster Ave
Accounting
Green Bay, WI 54301-3505
744 S Webster Ave
Green Bay, WI 54301-3505
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in WI
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: No
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20160707000393 | WI | Practitioner - Physician Assistant | 8820380132 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Physician Assistant
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 1135070 | WI | MD | Physician Assistant |
| 3761-23 | WI | MD | Physician Assistant |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Bellin Memorial Hospital Inc | Occupational Therapist | Current |
Accepting new patients |
| Bellin Memorial Hospital Inc | Current |
Accepting new patients | |
| Bellin Memorial Hospital Inc | Past | Accepting new patients | |
| Oconto Hospital & Medical Center Inc | Past | Accepting new patients |
Locations
933 Waube Ln
Green Bay, WI 54304
Phone (920) 548-9500
744 S Webster Ave
Green Bay, WI 54301
Phone (920) 433-6025
3415 Custer St
Ste D
Manitowoc, WI 54220
Phone (920) 652-9310
2820 Roosevelt Rd
Marinette, WI 54143
Phone (715) 330-6171
820 Arbutus Ave
Oconto, WI 54153
Phone (920) 835-1100
Interoperability endpoints
- ljandrin925191@direct.emplifyhealth.org
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Occupational Therapist | 225X00000X | 4712 | WI | |
| Physician Assistant | 363A00000X | 1135070 | WI | |
| Physician Assistant | 363A00000X | 3761-23 | WI | Yes |
Addresses
Primary practice location
1970 S Ridge Rd
Green Bay, WI 54304-4125
Mailing address
PO Box 22487
Green Bay, WI 54305-2487
Phone (920) 445-7210
Other practice location 1
1160 Kepler Dr
Green Bay, WI 54311-8321
Phone (920) 288-5555
Other practice location 2
2820 Roosevelt Rd
Marinette, WI 54143-3834
Phone (715) 735-5225
Other practice location 3
3415 Custer St Ste D
Manitowoc, WI 54220-4328
Phone (920) 652-9310
Other practice location 4
820 Arbutus Ave
Oconto, WI 54153-2004
Phone (920) 835-1100
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1135070 | Other | NATIONAL COMMISSION ON CERTIFICATION OF PHYSICIAN ASSISTANTS |
Other names
- Lacey L Bartz
Other providers in Green Bay, WI
- James M Spitzer D.D.S. S.C.
- Debra S James-John
- Ashley Jan
- Stephen F Janas
- John Michael Janczakowski
- Erica Janisch
- Michael A Janitch
- Keith Jankuski
- Lindsey B Janowski
- Rachel Marie Janowski
All providers in Green Bay, WI · Physician Assistant in Wisconsin
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jan 30, 2023. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.