Provider Demographics
NPI:1669750386
Name:LACY, TYSON A (CRNA)
Entity type:Individual
Prefix:
First Name:TYSON
Middle Name:A
Last Name:LACY
Suffix:
Gender:M
Credentials:CRNA
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 2897
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67201-2897
Mailing Address - Country:US
Mailing Address - Phone:800-374-5326
Mailing Address - Fax:800-374-7656
Practice Address - Street 1:600 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:KS
Practice Address - Zip Code:67114-8780
Practice Address - Country:US
Practice Address - Phone:316-804-6213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-29
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1390058032163W00000X
KSTMP143428367500000X
KS557048367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse