Provider Demographics
NPI:1225430879
Name:LACHCIK, CLARK (PA-C)
Entity Type:Individual
Prefix:
First Name:CLARK
Middle Name:
Last Name:LACHCIK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1470 PARADISE CT
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32952-5560
Mailing Address - Country:US
Mailing Address - Phone:321-446-0689
Mailing Address - Fax:
Practice Address - Street 1:1775 W HIBISCUS BLVD
Practice Address - Street 2:SUITE 215
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-2620
Practice Address - Country:US
Practice Address - Phone:321-837-3820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-25
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9108265363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL013828000Medicaid