Provider Demographics
NPI:1477236347
Name:TRAYNOR, PATRICK LACKMANN (RD)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:LACKMANN
Last Name:TRAYNOR
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:671 RIVER RANCH ROAD
Mailing Address - Street 2:
Mailing Address - City:MARKLEEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:96120
Mailing Address - Country:US
Mailing Address - Phone:909-653-3471
Mailing Address - Fax:949-269-0134
Practice Address - Street 1:3079 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150
Practice Address - Country:US
Practice Address - Phone:909-653-3471
Practice Address - Fax:949-269-0134
Is Sole Proprietor?:No
Enumeration Date:2023-08-08
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86082088133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered