Provider Demographics
NPI:1083175244
Name:LACEY, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:LACEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 W. CHARLESTON BLVD.
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102
Mailing Address - Country:US
Mailing Address - Phone:702-383-2000
Mailing Address - Fax:702-671-2376
Practice Address - Street 1:1800 W. CHARLESTON BLVD.
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102
Practice Address - Country:US
Practice Address - Phone:702-383-2000
Practice Address - Fax:702-671-2376
Is Sole Proprietor?:No
Enumeration Date:2019-03-28
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVDO3338207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine