Provider Demographics
NPI:1689432155
Name:LACOURSE, MYA ANN
Entity Type:Individual
Prefix:
First Name:MYA
Middle Name:ANN
Last Name:LACOURSE
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 1:215 5TH ST
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-4033
Mailing Address - Country:US
Mailing Address - Phone:216-408-9447
Mailing Address - Fax:
Practice Address - Street 1:10100 HAWKE RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA STATION
Practice Address - State:OH
Practice Address - Zip Code:44028-9130
Practice Address - Country:US
Practice Address - Phone:216-408-9447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-11
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant