Provider Demographics
NPI:1972521474
Name:LUCIER, MARC M (CRNA)
Entity type:Individual
Prefix:
First Name:MARC
Middle Name:M
Last Name:LUCIER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3181 SW SAM JACKSON PARK RD
Mailing Address - Street 2:MAILCODE SJH-2
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3011
Mailing Address - Country:US
Mailing Address - Phone:503-494-4910
Mailing Address - Fax:503-494-8368
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3011
Practice Address - Country:US
Practice Address - Phone:503-494-4910
Practice Address - Fax:503-494-8368
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201810825CRNA367500000X
OHRN306174367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00727914OtherTRAVELERS RR MEDICARE
MIOH16131105Medicare ID - Type Unspecified
OHP00727914OtherTRAVELERS RR MEDICARE