Provider Demographics
NPI:1639612013
Name:BYRAM, LACEY HAUSER (PA)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:HAUSER
Last Name:BYRAM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 KINGS HWY
Mailing Address - Street 2:P.O. BOX 33932
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-4228
Mailing Address - Country:US
Mailing Address - Phone:318-675-6180
Mailing Address - Fax:
Practice Address - Street 1:1541 KINGS HWY
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4228
Practice Address - Country:US
Practice Address - Phone:318-675-6180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-02
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA303570363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant