Provider Demographics
NPI:1699972679
Name:KONOVALENKO, LUCAS W (MD)
Entity type:Individual
Prefix:DR
First Name:LUCAS
Middle Name:W
Last Name:KONOVALENKO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:LUCAS
Other - Middle Name:W
Other - Last Name:CAMPOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:935 TRANCAS ST STE 4B
Mailing Address - Street 2:
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94558-2943
Mailing Address - Country:US
Mailing Address - Phone:707-346-4444
Mailing Address - Fax:877-354-4771
Practice Address - Street 1:935 TRANCAS ST STE 4B
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558-2943
Practice Address - Country:US
Practice Address - Phone:707-346-4444
Practice Address - Fax:877-354-4771
Is Sole Proprietor?:No
Enumeration Date:2007-07-02
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301089987207L00000X
CAA135704207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0412253OtherBCBS PIN
MIM71590135Medicare PIN
MI0412253OtherBCBS PIN