Provider Demographics
NPI:1972057784
Name:LUCERO-DAGA, SAMANTHA LACY (NP)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LACY
Last Name:LUCERO-DAGA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:791 E FOOTHILL BLVD
Mailing Address - Street 2:SUITE N
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4018
Mailing Address - Country:US
Mailing Address - Phone:909-297-0728
Mailing Address - Fax:
Practice Address - Street 1:9701 W PICO BLVD
Practice Address - Street 2:STE 100
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90035-4744
Practice Address - Country:US
Practice Address - Phone:310-500-8277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-10
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95004284363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily