Individual
DR. ANDREA JUNE LACK
Active
Individual
DR. ANDREA JUNE LACK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
69193
TN
207R00000X
Internal Medicine Physician
Q5461
TX
208000000X
Pediatrics Physician
Q5461
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1679524961
LEGACY COMMUNITY HEALTH SERVICES INC MEDICAID #
TX
01
—
741819
LEGACY SITE SPECIFIC MEDICARE #
TX
01
—
BP10041723
TEXAS MEDICAL BOARD PHYSICIAN IN TRAINING PERMIT
TX
01
—
Q5461
TX MEDICAL BOARD LICENSE EFF 8/3/15
TX
Enumeration date
06/14/2011
Last updated
11/08/2023
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