Provider Demographics
NPI:1194951418
Name:BOYD, LACY (PA)
Entity type:Individual
Prefix:
First Name:LACY
Middle Name:
Last Name:BOYD
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 1:2721 W PARK DR
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-9058
Mailing Address - Country:US
Mailing Address - Phone:270-554-7546
Mailing Address - Fax:270-554-0316
Practice Address - Street 1:2721 W PARK DR
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-9058
Practice Address - Country:US
Practice Address - Phone:270-554-7546
Practice Address - Fax:270-554-0316
Is Sole Proprietor?:No
Enumeration Date:2009-06-01
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA1142363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000755001OtherANTHEM
KYP01058489OtherRR MEDICARE
KYK037980Medicare PIN