Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207R00000X | Internist | 9600341 | NC |
Y | 111NI0900X | Internist | 9600341 | NC |
N | 207RI0200X | Infectious Disease | 9600341 | NC |
N | 207RI0200X | Infectious Disease | MD20293 | SC |
NPI | 1083690325 |
---|---|
Provider Name | Philip Lackey |
First Address | Charlotte, NC 28210-3281 |
Second Address | Charlotte, NC 28210-3281 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/12/2005 |
Last Update Date | 29/05/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
E90912 | (02) | NC |