Healthcare Provider Details

I. General information

NPI: 1073477089
Provider Name (Legal Business Name): JOSEPH WILLIAM LACKNER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2025
Last Update Date: 12/13/2025
Certification Date: 12/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 GOLF COURSE RD
GRAND RAPIDS MN
55744-8648
US

IV. Provider business mailing address

209 3RD ST S
VIRGINIA MN
55792-2619
US

V. Phone/Fax

Practice location:
  • Phone: 218-326-3401
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number15633
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: