Healthcare Provider Details

I. General information

NPI: 1164892204
Provider Name (Legal Business Name): KACEY RAE LOPEZ PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KACEY RAE BUCKNER PA

II. Dates (important events)

Enumeration Date: 10/01/2015
Last Update Date: 06/26/2023
Certification Date: 06/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 AMBASSADOR CAFFERY PARKWAY
LAFAYETTE LA
70508-3983
US

IV. Provider business mailing address

5959 S SHERWOOD FOREST BLVD
BATON ROUGE LA
70816-6038
US

V. Phone/Fax

Practice location:
  • Phone: 337-470-2605
  • Fax: 337-470-4595
Mailing address:
  • Phone: 225-526-0636
  • Fax: 225-765-9616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number300080
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number300080
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: