Provider Demographics
NPI:1124498944
Name:LUCCA, AXEL
Entity type:Individual
Prefix:
First Name:AXEL
Middle Name:
Last Name:LUCCA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6230 ROLLING RD STE J
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22152-2326
Mailing Address - Country:US
Mailing Address - Phone:571-889-3235
Mailing Address - Fax:571-889-3236
Practice Address - Street 1:6230 ROLLING RD STE J
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22152-2326
Practice Address - Country:US
Practice Address - Phone:571-889-3235
Practice Address - Fax:571-889-3236
Is Sole Proprietor?:No
Enumeration Date:2015-10-06
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110005033363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant