Provider Demographics
NPI:1588907638
Name:LACY, JON CHARLES (PA)
Entity type:Individual
Prefix:MR
First Name:JON
Middle Name:CHARLES
Last Name:LACY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
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Mailing Address - Street 1:6368 HOLLYWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90028-6320
Mailing Address - Country:US
Mailing Address - Phone:323-469-5555
Mailing Address - Fax:323-466-0405
Practice Address - Street 1:6368 HOLLYWOOD BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90028-6320
Practice Address - Country:US
Practice Address - Phone:323-469-5555
Practice Address - Fax:323-466-0405
Is Sole Proprietor?:No
Enumeration Date:2013-03-27
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPA22770363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical