Provider Demographics
NPI:1073911087
Name:LUCAS, LORENZEN
Entity Type:Individual
Prefix:
First Name:LORENZEN
Middle Name:
Last Name:LUCAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 B ST BLDG A
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:CA
Mailing Address - Zip Code:95334-9593
Mailing Address - Country:US
Mailing Address - Phone:209-850-3500
Mailing Address - Fax:
Practice Address - Street 1:600 B ST
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:CA
Practice Address - Zip Code:95334-9593
Practice Address - Country:US
Practice Address - Phone:209-850-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-08
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA09585363A00000X
CAPA54129363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA09585OtherTEXAS MEDICAL BOARD
TX346983501Medicaid
TXPA09585OtherTEXAS MEDICAL BOARD