Provider Demographics
NPI:1982283149
Name:LUCAS, TRACEY ANN
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:ANN
Last Name:LUCAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 PADDOCK LN
Mailing Address - Street 2:
Mailing Address - City:SOUTHERN PINES
Mailing Address - State:NC
Mailing Address - Zip Code:28387-2948
Mailing Address - Country:US
Mailing Address - Phone:614-632-8625
Mailing Address - Fax:
Practice Address - Street 1:7496 ROCKFISH RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28306-8076
Practice Address - Country:US
Practice Address - Phone:910-424-2905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-05
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCNP0028534363L00000X, 363LF0000X
NC5017806363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1982283149Medicaid