Provider Demographics
NPI:1194120535
Name:MALIWACKI, LUCAS W (PA-C)
Entity type:Individual
Prefix:
First Name:LUCAS
Middle Name:W
Last Name:MALIWACKI
Suffix:
Gender:M
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 1:367 S. GULPH RD
Mailing Address - Street 2:ATT: IPM CREDENTIALING
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-3121
Mailing Address - Country:US
Mailing Address - Phone:775-356-9393
Mailing Address - Fax:775-356-5590
Practice Address - Street 1:4647 MANATEE AVE W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-3816
Practice Address - Country:US
Practice Address - Phone:941-745-5999
Practice Address - Fax:941-745-3555
Is Sole Proprietor?:No
Enumeration Date:2014-10-28
Last Update Date:2017-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9108377363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIA038YMedicare PIN