Provider Demographics
NPI:1992038574
Name:MCMANUS, LACEY GORHAM (PA)
Entity type:Individual
Prefix:
First Name:LACEY
Middle Name:GORHAM
Last Name:MCMANUS
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 1:265 L SULLIVAN RD
Mailing Address - Street 2:
Mailing Address - City:WINNFIELD
Mailing Address - State:LA
Mailing Address - Zip Code:71483-6451
Mailing Address - Country:US
Mailing Address - Phone:318-209-9584
Mailing Address - Fax:
Practice Address - Street 1:431 W LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:WINNFIELD
Practice Address - State:LA
Practice Address - Zip Code:71483-3463
Practice Address - Country:US
Practice Address - Phone:318-648-0375
Practice Address - Fax:318-648-0378
Is Sole Proprietor?:No
Enumeration Date:2009-09-14
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA.200367363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant