Provider Demographics
NPI:1972729507
Name:MARES, LUCIO I (PA)
Entity type:Individual
Prefix:MR
First Name:LUCIO
Middle Name:I
Last Name:MARES
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:144 FALCON BLVD APT 2
Mailing Address - Street 2:
Mailing Address - City:EAGLE PASS
Mailing Address - State:TX
Mailing Address - Zip Code:78852-5861
Mailing Address - Country:US
Mailing Address - Phone:830-513-1123
Mailing Address - Fax:830-773-2981
Practice Address - Street 1:144 FALCON BLVD APT 2
Practice Address - Street 2:
Practice Address - City:EAGLE PASS
Practice Address - State:TX
Practice Address - Zip Code:78852-5861
Practice Address - Country:US
Practice Address - Phone:830-513-1123
Practice Address - Fax:830-773-2981
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00646363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8A3519Medicare ID - Type Unspecified
TXR77226Medicare UPIN