Provider Demographics
NPI:1003843640
Name:LAZENBY, AUDREY J (MD)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:J
Last Name:LAZENBY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:988102 NEBRASKA MEDICAL CTR
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68198-8102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:EMILE @ 42ND ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68198-0001
Practice Address - Country:US
Practice Address - Phone:402-559-4186
Practice Address - Fax:402-559-6018
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL18693207ZP0101X
NE23983207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051530857OtherBLUE CROSS
AL000025160Medicaid
LA1595934OtherEMERGENCY LA MEDICAID
AL220015991OtherRAILROAD MEDICARE
ALE36147OtherVIVA
AL000025160OtherBLUE CROSS