Healthcare Provider Details

I. General information

NPI: 1265915268
Provider Name (Legal Business Name): BRIANA M LACKMAN PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2018
Last Update Date: 09/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

470 TOLL GATE RD STE 203
WARWICK RI
02886-2741
US

IV. Provider business mailing address

470 TOLL GATE RD STE 203
WARWICK RI
02886-2741
US

V. Phone/Fax

Practice location:
  • Phone: 401-751-1235
  • Fax:
Mailing address:
  • Phone: 401-751-1235
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA01081
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: