Provider Demographics
NPI:1487998605
Name:ADAMS LACKEY, PAMELA LYNN (PA-C)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:LYNN
Last Name:ADAMS LACKEY
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:ROUTE 7A NORTH
Mailing Address - Street 2:5957 MAIN STREET
Mailing Address - City:MANCHESTER CENTER
Mailing Address - State:VT
Mailing Address - Zip Code:05255-8913
Mailing Address - Country:US
Mailing Address - Phone:802-362-4440
Mailing Address - Fax:
Practice Address - Street 1:ROUTE 7A NORTH
Practice Address - Street 2:5957 MAIN STREET
Practice Address - City:MANCHESTER CENTER
Practice Address - State:VT
Practice Address - Zip Code:05255-8913
Practice Address - Country:US
Practice Address - Phone:802-362-4440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2020-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0550031150363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH33300169Medicaid
VT9000586Medicaid