Provider Demographics
NPI:1215057799
Name:LACKI, ANDREA LYNNE (PA-C)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:LYNNE
Last Name:LACKI
Suffix:
Gender:F
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 1:614 N TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16602-2965
Mailing Address - Country:US
Mailing Address - Phone:814-441-4861
Mailing Address - Fax:
Practice Address - Street 1:3000 FAIRWAY DR
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16602-4472
Practice Address - Country:US
Practice Address - Phone:814-962-1166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2010-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0003589363AS0400X
VA0110002349363A00000X
PAMA053507363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant