Healthcare Provider Details

I. General information

NPI: 1295718898
Provider Name (Legal Business Name): ANTHONY N LACKEY P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/29/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 W MAGNETIC ST SUITE ER
MARQUETTE MI
49855-2711
US

IV. Provider business mailing address

PO BOX 220
MARQUETTE MI
49855-0220
US

V. Phone/Fax

Practice location:
  • Phone: 888-674-0854
  • Fax: 906-225-3370
Mailing address:
  • Phone: 888-674-0854
  • Fax: 906-225-3370

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601003024
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: