Healthcare Provider Details

I. General information

NPI: 1881986982
Provider Name (Legal Business Name): EVAN LACEFIELD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2011
Last Update Date: 09/17/2024
Certification Date: 09/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 E 29TH ST STE 100
BRYAN TX
77802-2507
US

IV. Provider business mailing address

2700 E 29TH ST STE 100
BRYAN TX
77802-2507
US

V. Phone/Fax

Practice location:
  • Phone: 979-774-3041
  • Fax: 979-774-3053
Mailing address:
  • Phone: 979-774-3041
  • Fax: 979-774-3053

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberQ7572
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: