Provider Demographics
NPI:1265915268
Name:LACKMAN, BRIANA M (PAC)
Entity type:Individual
Prefix:
First Name:BRIANA
Middle Name:M
Last Name:LACKMAN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:470 TOLL GATE RD STE 203
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-2741
Mailing Address - Country:US
Mailing Address - Phone:401-751-1235
Mailing Address - Fax:
Practice Address - Street 1:470 TOLL GATE RD STE 203
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-2741
Practice Address - Country:US
Practice Address - Phone:401-751-1235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-14
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPA01081363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant