Healthcare Provider Details

I. General information

NPI: 1700981206
Provider Name (Legal Business Name): ROBERT L LACKEY PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 12/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 VANDERBILT PARK DR
ASHEVILLE NC
28803-1700
US

IV. Provider business mailing address

PO BOX 602811
CHARLOTTE NC
28260-2811
US

V. Phone/Fax

Practice location:
  • Phone: 828-255-7776
  • Fax: 282-274-5134
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number742
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-05849
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number0010-05849
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: