MEDICARE: MR. JON CHARLES LACY PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	PA22770	CA

General Provider Information

NPI Number	:	1588907638
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JON CHARLES LACY PA

Provider Business Mailing Address
First Line	:	6368 HOLLYWOOD BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90028-6320
Country	:	US
Telephone Number	:	323-469-5555
Fax Number	:	323-466-0405

Provider Business Practice Location Address
First Line	:	6368 HOLLYWOOD BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90028-6320
Country	:	US
Telephone Number	:	323-469-5555
Fax Number	:	323-466-0405

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/27/2013
Last Update Date	:	09/21/2016

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