Provider Demographics
NPI:1255889853
Name:BOHANNON, LAKIESHA (PA)
Entity type:Individual
Prefix:
First Name:LAKIESHA
Middle Name:
Last Name:BOHANNON
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 1:3600 SHIRE BLVD STE 104
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75082-2236
Mailing Address - Country:US
Mailing Address - Phone:972-487-6400
Mailing Address - Fax:
Practice Address - Street 1:3600 SHIRE BLVD STE 104
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75082-2236
Practice Address - Country:US
Practice Address - Phone:972-487-6400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-13
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA13729363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical