Provider Demographics
NPI:1558905653
Name:BAUER, LACI (NP-C)
Entity Type:Individual
Prefix:
First Name:LACI
Middle Name:
Last Name:BAUER
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 S EAGLE RD STE 1243
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-6355
Mailing Address - Country:US
Mailing Address - Phone:208-333-2225
Mailing Address - Fax:
Practice Address - Street 1:520 S EAGLE RD
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6351
Practice Address - Country:US
Practice Address - Phone:208-333-2225
Practice Address - Fax:208-706-7516
Is Sole Proprietor?:No
Enumeration Date:2019-10-31
Last Update Date:2019-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID62999363L00000X, 207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner