Provider Demographics
NPI:1932350790
Name:UPSHAW, LUCIUS K (PA-C)
Entity type:Individual
Prefix:
First Name:LUCIUS
Middle Name:K
Last Name:UPSHAW
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:50 S SAN MATEO DR
Mailing Address - Street 2:SUITE 440
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-3857
Mailing Address - Country:US
Mailing Address - Phone:650-558-0504
Mailing Address - Fax:650-558-0323
Practice Address - Street 1:50 S SAN MATEO DR
Practice Address - Street 2:SUITE 440
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-3857
Practice Address - Country:US
Practice Address - Phone:650-558-0504
Practice Address - Fax:650-558-0323
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-09
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA19952363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant