Healthcare Provider Details

I. General information

NPI: 1578908075
Provider Name (Legal Business Name): LACYE DAWN ESCAMILLA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2013
Last Update Date: 02/14/2024
Certification Date: 02/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2626 N BRYANT BLVD
SAN ANGELO TX
76903-2861
US

IV. Provider business mailing address

PO BOX 22000
SAN ANGELO TX
76902-7200
US

V. Phone/Fax

Practice location:
  • Phone: 325-747-2271
  • Fax:
Mailing address:
  • Phone: 325-747-1511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA08330
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: