Doctor Name: | JOHN LACKEY |
NPI Number: | 1063456648 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | MD |
License Number: | M3873 |
Business Practice Address: | 500 S 11th Ave Pocatello, ID - 832014835 |
Business Phone Number: | 2082323103 |
Business Fax Number: | 2082320756 |
Mailing Address: | 700 Canyon Dr, POCATELLO |
State: | ID |
Postal Code: | 832044840 |
Phone Number: | 2082341921 |
Fax Number: | |
NPI Enumeration Date: | 06/15/2006 |
NPI Last Update Date: | 07/08/2007 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 174400000X |
License Number: | M3873 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | ID |
Taxonomy Type: | Other Service Providers |
Taxonomy Classification: | Specialist |
Taxonomy Specialization: | |
Taxonomy Definition: | An individual educated and trained in an applied knowledge discipline used in the performance of work at a level requiring knowledge and skills beyond or apart from that provided by a general education or liberal arts degree. |