Provider Demographics
NPI:1932381357
Name:LACY, DARRYL O (PA)
Entity Type:Individual
Prefix:
First Name:DARRYL
Middle Name:O
Last Name:LACY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:128 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:ALAMOSA
Mailing Address - State:CO
Mailing Address - Zip Code:81101-2290
Mailing Address - Country:US
Mailing Address - Phone:719-589-5161
Mailing Address - Fax:719-589-5722
Practice Address - Street 1:903 S 12TH ST
Practice Address - Street 2:
Practice Address - City:ROCKY FORD
Practice Address - State:CO
Practice Address - Zip Code:81067-2127
Practice Address - Country:US
Practice Address - Phone:719-254-7623
Practice Address - Fax:719-254-5112
Is Sole Proprietor?:No
Enumeration Date:2007-11-27
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2537363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant