Provider Demographics
NPI:1720685993
Name:BUSBY, LACE THOMAS III
Entity Type:Individual
Prefix:MR
First Name:LACE
Middle Name:THOMAS
Last Name:BUSBY
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20523 CREEK RIV
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78259-2083
Mailing Address - Country:US
Mailing Address - Phone:270-627-0474
Mailing Address - Fax:
Practice Address - Street 1:1434 E SONTERRA BLVD STE 206
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-4973
Practice Address - Country:US
Practice Address - Phone:210-402-3456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-01
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1002899363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily