Provider Demographics
NPI:1255866877
Name:LACEY, TYLER (MD)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:LACEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6600 EXCELSIOR BLVD
Mailing Address - Street 2:STE. 160
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426-4744
Mailing Address - Country:US
Mailing Address - Phone:952-993-7705
Mailing Address - Fax:
Practice Address - Street 1:6600 EXCELSIOR BLVD
Practice Address - Street 2:STE. 160
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-4744
Practice Address - Country:US
Practice Address - Phone:952-993-7705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-21
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program