Provider Demographics
NPI:1699735803
Name:LUCAS, ANTONETTE (NP)
Entity type:Individual
Prefix:MRS
First Name:ANTONETTE
Middle Name:
Last Name:LUCAS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:ANTONETTE
Other - Middle Name:
Other - Last Name:SORRELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-6270
Mailing Address - Fax:
Practice Address - Street 1:136 E ASH ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2217
Practice Address - Country:US
Practice Address - Phone:601-352-6507
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2010-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR860519363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS253418OtherMEDICARE RURAL HEALTH
MS04535731Medicaid
MS04535731Medicaid
MS500001986Medicare PIN