Provider Demographics
NPI:1316306723
Name:LUCAS, JOHN M (CRNA)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:LUCAS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 PINE LN
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26508-8827
Mailing Address - Country:US
Mailing Address - Phone:304-641-5484
Mailing Address - Fax:
Practice Address - Street 1:306 STANAFORD RD
Practice Address - Street 2:ANESTHESIA DEPARTMENT
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801
Practice Address - Country:US
Practice Address - Phone:304-255-3246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-12
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV76057367500000X
MDAC002240367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered