Provider Demographics
NPI:1487975827
Name:WANER, LACI DESIRAE (MD)
Entity type:Individual
Prefix:DR
First Name:LACI
Middle Name:DESIRAE
Last Name:WANER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LACI
Other - Middle Name:DESIRAE
Other - Last Name:STEPHENSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2710 OAK RDG
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:TX
Mailing Address - Zip Code:76634-1162
Mailing Address - Country:US
Mailing Address - Phone:979-575-7936
Mailing Address - Fax:
Practice Address - Street 1:2710 OAK RDG
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:TX
Practice Address - Zip Code:76634-1162
Practice Address - Country:US
Practice Address - Phone:254-424-1243
Practice Address - Fax:502-385-6556
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-21
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK29766207Q00000X
FLME143348207Q00000X
TXR1902207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX369616303Medicaid
TX369616301Medicaid