Provider Demographics
NPI:1497080717
Name:LACKEY, JAMES M (PA-C)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:M
Last Name:LACKEY
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 1:200 ROUTE 98 W ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:NUTTER FORT
Mailing Address - State:WV
Mailing Address - Zip Code:26301-4385
Mailing Address - Country:US
Mailing Address - Phone:304-623-6330
Mailing Address - Fax:304-623-1333
Practice Address - Street 1:200 ROUTE 98 W ST
Practice Address - Street 2:SUITE 103
Practice Address - City:NUTTER FORT
Practice Address - State:WV
Practice Address - Zip Code:26301-4385
Practice Address - Country:US
Practice Address - Phone:304-623-6330
Practice Address - Fax:304-623-1333
Is Sole Proprietor?:No
Enumeration Date:2009-10-05
Last Update Date:2009-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVTEMP363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical