Provider Demographics
NPI:1396121646
Name:ANDERSON, LUCAS MICHAL
Entity type:Individual
Prefix:
First Name:LUCAS
Middle Name:MICHAL
Last Name:ANDERSON
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 1:6317 N PARK DR
Mailing Address - Street 2:
Mailing Address - City:WATAUGA
Mailing Address - State:TX
Mailing Address - Zip Code:76148-1321
Mailing Address - Country:US
Mailing Address - Phone:707-738-0510
Mailing Address - Fax:
Practice Address - Street 1:6317 N PARK DR
Practice Address - Street 2:
Practice Address - City:WATAUGA
Practice Address - State:TX
Practice Address - Zip Code:76148-1321
Practice Address - Country:US
Practice Address - Phone:707-738-0510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-09
Last Update Date:2022-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52540363AM0700X
NVPA1668363AM0700X
TXPA14846363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVLA1225Medicaid
TX1396121646Medicaid
NVLA1225Medicare Oscar/Certification
NVLA1225Medicaid