MEDICARE: KACEY MD LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	207Q00000X	Family Medicine Physician
2	207RC0000X	Cardiovascular Disease Physician
3	2084N0400X	Neurology Physician
4	2084P0800X	Psychiatry Physician
5	208VP0000X	Pain Medicine Physician
6	363A00000X	Physician Assistant
7	363L00000X	Nurse Practitioner
8	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1699102442
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KACEY MD LLC

Provider Business Mailing Address
First Line	:	1033 RAILROAD FLAT CT
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89138-4521
Country	:	US
Telephone Number	:	312-823-6126
Fax Number	:

Provider Business Practice Location Address
First Line	:	1033 RAILROAD FLAT CT
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89138-4521
Country	:	US
Telephone Number	:	312-823-6126
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KASEY LAZ ABANONU
Credential	:	MD
Telephone Number	:	312-823-6126

Provider Enumeration Date	:	10/10/2013
Last Update Date	:	03/17/2022

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