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General NPI Number Information
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NPI Number | 1306879192
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Entity Type | Individual
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Provider Name | JEFFREY L LACKORE PA
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Gender | Male
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Dates
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Enumeration Date | 07/08/2006
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Last Update Date | 08/24/2009
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Provider Practice Location Address
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Address Line | 6120 SANDHURST DR
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City | ROANOKE
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State | VA
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Zip | 24018-7798
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Country | US
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Telephone | 712-253-6104
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Fax |
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Provider Business Mailing Address
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Address Line | 6120 SANDHURST DR
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City | ROANOKE
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State | VA
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Zip | 24018-7798
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 0110001943
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA20332
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License Number State | CA
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