Provider Demographics
NPI:1912208752
Name:LACKNER, MICHAEL JOESPH (PA)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JOESPH
Last Name:LACKNER
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:PO BOX 29234
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10087-4923
Mailing Address - Country:US
Mailing Address - Phone:631-329-6925
Mailing Address - Fax:631-329-6951
Practice Address - Street 1:535 E 70TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-4823
Practice Address - Country:US
Practice Address - Phone:212-774-2837
Practice Address - Fax:646-797-8428
Is Sole Proprietor?:No
Enumeration Date:2010-11-10
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY014415-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03328470Medicaid
A400102068Medicare PIN