Healthcare Provider Details

I. General information

NPI: 1740771054
Provider Name (Legal Business Name): MANDY LOCKARD PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2018
Last Update Date: 05/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 BRENNER AVE
SALISBURY NC
28144-2515
US

IV. Provider business mailing address

155 WATERS RD
SALISBURY NC
28146-7623
US

V. Phone/Fax

Practice location:
  • Phone: 704-638-9000
  • Fax:
Mailing address:
  • Phone: 336-460-1729
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: