Provider Demographics
NPI:1013245257
Name:BYRD CHEESEMAN, KACI M (PA)
Entity Type:Individual
Prefix:
First Name:KACI
Middle Name:M
Last Name:BYRD CHEESEMAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KACI
Other - Middle Name:MARIE
Other - Last Name:BYRD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:251 N BAYOU ST
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36603-5827
Mailing Address - Country:US
Mailing Address - Phone:251-690-8158
Mailing Address - Fax:251-544-2188
Practice Address - Street 1:950 W COY SMITH HWY
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:AL
Practice Address - Zip Code:36560-3201
Practice Address - Country:US
Practice Address - Phone:251-829-9884
Practice Address - Fax:251-829-9507
Is Sole Proprietor?:No
Enumeration Date:2009-11-30
Last Update Date:2013-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA681363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1063439065OtherGROUP NPI PAYEE NUMBER
AL630000013Medicaid
AL011846OtherMAIN GROUP MEDICARE PAYEE NUMBER