Provider Demographics
NPI:1104394337
Name:BELFORD, LUCAS P (PA)
Entity Type:Individual
Prefix:
First Name:LUCAS
Middle Name:P
Last Name:BELFORD
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 1:909 E RESERVE ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6508
Mailing Address - Country:US
Mailing Address - Phone:502-544-1780
Mailing Address - Fax:
Practice Address - Street 1:700 E ALICE ST
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-4925
Practice Address - Country:US
Practice Address - Phone:208-785-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-06
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1676363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant