Provider Demographics
NPI:1396989109
Name:LUCAS, NINA DEWI (MD)
Entity type:Individual
Prefix:DR
First Name:NINA
Middle Name:DEWI
Last Name:LUCAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:NINA
Other - Middle Name:LUCAS
Other - Last Name:BETETA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:905 HALSTEAD BLVD STE 29
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-6816
Mailing Address - Country:US
Mailing Address - Phone:252-698-0345
Mailing Address - Fax:252-698-0346
Practice Address - Street 1:905 HALSTEAD BLVD STE 29
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-6816
Practice Address - Country:US
Practice Address - Phone:252-698-0345
Practice Address - Fax:252-698-0346
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2012-01569207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVV4029A - C03895Medicare PIN
MD236410ZDDB (149619)Medicare PIN
MD236410YVZ - (945L)Medicare PIN