Provider Demographics
NPI:1316956998
Name:LUCAS, SHELBY (PA-C)
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:
Last Name:LUCAS
Suffix:
Gender:F
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 1:908 N ROCKFORD ROAD
Mailing Address - Street 2:SUITE A
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-2541
Mailing Address - Country:US
Mailing Address - Phone:580-226-7771
Mailing Address - Fax:580-226-7788
Practice Address - Street 1:908 N ROCKFORD ROAD
Practice Address - Street 2:SUITE A
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-2541
Practice Address - Country:US
Practice Address - Phone:580-226-7771
Practice Address - Fax:580-226-7788
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1325363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200043090BMedicaid
OK200043090BMedicaid
OK241412003Medicare ID - Type Unspecified