Basic Information
| Provider Information | |||||||||
| NPI: | 1427583285 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LACKMAN | ||||||||
| FirstName: | KENA | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 104 RUFUS LN | ||||||||
| Address2: | |||||||||
| City: | POLSON | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598608903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4068832555 | ||||||||
| FaxNumber: | 4068832559 | ||||||||
| Practice Location | |||||||||
| Address1: | 104 RUFUS LN | ||||||||
| Address2: | |||||||||
| City: | POLSON | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598608903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4068832555 | ||||||||
| FaxNumber: | 4068832559 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2017 | ||||||||
| LastUpdateDate: | 10/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MRM-1634 | ID | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.