Provider Demographics
NPI:1992038574
Name:MCMANUS, LACEY GORHAM (PA)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:GORHAM
Last Name:MCMANUS
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 1:265 L SULLIVAN RD
Mailing Address - Street 2:
Mailing Address - City:WINNFIELD
Mailing Address - State:LA
Mailing Address - Zip Code:71483-6451
Mailing Address - Country:US
Mailing Address - Phone:318-607-8861
Mailing Address - Fax:318-648-2270
Practice Address - Street 1:639 W LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:WINNFIELD
Practice Address - State:LA
Practice Address - Zip Code:71483-3451
Practice Address - Country:US
Practice Address - Phone:318-648-2220
Practice Address - Fax:318-648-2270
Is Sole Proprietor?:No
Enumeration Date:2009-09-14
Last Update Date:2009-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA.EXAM.703363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant