Provider Demographics
NPI:1003177726
Name:LACY COKER KESSLER, MD, PA
Entity Type:Organization
Organization Name:LACY COKER KESSLER, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:J
Authorized Official - Last Name:ELLIOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:254-420-0002
Mailing Address - Street 1:2420 WYCON DR
Mailing Address - Street 2:SUITE 403
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76712-8987
Mailing Address - Country:US
Mailing Address - Phone:254-420-0002
Mailing Address - Fax:
Practice Address - Street 1:2410 WYCON DR
Practice Address - Street 2:SUITE 204
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-8958
Practice Address - Country:US
Practice Address - Phone:254-420-0002
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-30
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP2879207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3064149-01Medicaid
TX3064149-01Medicaid