MEDICARE: JACOB GRAY LACKEY PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	0010-05288	NC
2	363AM0700X	Medical Physician Assistant	001005288	NC

General Provider Information

NPI Number	:	1699178731
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB GRAY LACKEY PA-C

Provider Business Mailing Address
First Line	:	PO BOX 601843
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28260-1843
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3163 GAMMON LN
Second Line	:
City	:	CLEMMONS
State	:	NC
Zip	:	27012-9052
Country	:	US
Telephone Number	:	336-310-5571
Fax Number	:	336-310-5574

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/03/2014
Last Update Date	:	08/18/2021

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