Provider Demographics
NPI:1164892204
Name:LOPEZ, KACEY RAE (PA)
Entity Type:Individual
Prefix:MS
First Name:KACEY
Middle Name:RAE
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KACEY
Other - Middle Name:RAE
Other - Last Name:BUCKNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:225-526-0636
Mailing Address - Fax:225-765-9616
Practice Address - Street 1:4801 AMBASSADOR CAFFERY PARKWAY
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-3983
Practice Address - Country:US
Practice Address - Phone:337-470-2605
Practice Address - Fax:337-470-4595
Is Sole Proprietor?:No
Enumeration Date:2015-10-01
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA300080363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical