Provider Demographics
NPI:1659476737
Name:WALTERS, LACY DAWN DAVIS (PA-C)
Entity Type:Individual
Prefix:
First Name:LACY
Middle Name:DAWN DAVIS
Last Name:WALTERS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LACY
Other - Middle Name:DAWN
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 6369
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59604-6369
Mailing Address - Country:US
Mailing Address - Phone:406-447-2823
Mailing Address - Fax:406-447-2825
Practice Address - Street 1:2550 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59601-4905
Practice Address - Country:US
Practice Address - Phone:208-724-4410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMED-PAC-LIC-26013363A00000X
IDPA-622363A00000X
IDPA622207VG0400X, 207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery