Provider Demographics
NPI:1245514785
Name:EATON, LACY KENNEDY (PA)
Entity type:Individual
Prefix:
First Name:LACY
Middle Name:KENNEDY
Last Name:EATON
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:PO BOX 4207
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75606-4207
Mailing Address - Country:US
Mailing Address - Phone:903-297-1733
Mailing Address - Fax:903-295-1600
Practice Address - Street 1:1761 W LOOP 281
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75604-2734
Practice Address - Country:US
Practice Address - Phone:903-297-1733
Practice Address - Fax:903-295-1600
Is Sole Proprietor?:No
Enumeration Date:2011-10-03
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA07377363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant