Provider Demographics
NPI:1134170772
Name:LACY, ELIZABETH A (DO)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:A
Last Name:LACY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 W 16TH ST
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-2781
Mailing Address - Country:US
Mailing Address - Phone:171-958-4430
Mailing Address - Fax:719-595-7886
Practice Address - Street 1:400 W 16TH ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2781
Practice Address - Country:US
Practice Address - Phone:719-584-4306
Practice Address - Fax:719-595-7886
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200300169174400000X
CA20A13779207P00000X
CODR.0060926207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC135YNOtherBSNC
NC89135YNMedicaid
NCG85998Medicare UPIN
NC2401319Medicare PIN