Individual
JEFFREY L LACKORE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA
Contact information
Practice address
6120 SANDHURST DR, ROANOKE, VA 24018-7798
(712) 253-6104
Mailing address
6120 SANDHURST DR, ROANOKE, VA 24018-7798
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
0110001943
VA
363A00000X
Physician Assistant
PA20332
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1306879192
—
CA
Enumeration date
07/08/2006
Last updated
08/24/2009
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