Provider Demographics
NPI:1891166344
Name:LACZ, KEVIN ROBERT (PA-C)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:ROBERT
Last Name:LACZ
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:423 N BAYLEN ST
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32501-3901
Mailing Address - Country:US
Mailing Address - Phone:850-816-9939
Mailing Address - Fax:
Practice Address - Street 1:100 S BAYLEN ST SUITE A
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32502-5825
Practice Address - Country:US
Practice Address - Phone:850-471-8399
Practice Address - Fax:850-807-5059
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-09
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9108469363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9108469OtherMEDICAL LICENSE
FLPA9108469OtherMEDICAL LICENSE