Healthcare Provider Details

I. General information

NPI: 1194951418
Provider Name (Legal Business Name): LACY BOYD PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2009
Last Update Date: 03/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2721 W PARK DR
PADUCAH KY
42001-9058
US

IV. Provider business mailing address

2721 W PARK DR
PADUCAH KY
42001-9058
US

V. Phone/Fax

Practice location:
  • Phone: 270-554-7546
  • Fax: 270-554-0316
Mailing address:
  • Phone: 270-554-7546
  • Fax: 270-554-0316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA1142
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA1142
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: