Provider Demographics
NPI:1447805098
Name:LACSON, MARIA LOIDA DELACRUZ
Entity Type:Individual
Prefix:
First Name:MARIA LOIDA
Middle Name:DELACRUZ
Last Name:LACSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10930 SWANSFIELD RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-2728
Mailing Address - Country:US
Mailing Address - Phone:301-943-3456
Mailing Address - Fax:
Practice Address - Street 1:9055 CHEVROLET DR
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-4016
Practice Address - Country:US
Practice Address - Phone:410-465-7850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-09
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILR156462363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDL-250-585-537-830OtherMD DRIVERS LICENSE