Provider Demographics
NPI:1134691835
Name:DOLAN, LUCAS CLAIR
Entity Type:Individual
Prefix:
First Name:LUCAS
Middle Name:CLAIR
Last Name:DOLAN
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 1:28633 DAYTON AVE
Mailing Address - Street 2:
Mailing Address - City:MILROY
Mailing Address - State:MN
Mailing Address - Zip Code:56263-1167
Mailing Address - Country:US
Mailing Address - Phone:507-828-3142
Mailing Address - Fax:
Practice Address - Street 1:917 7TH AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2601
Practice Address - Country:US
Practice Address - Phone:360-425-5910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-19
Last Update Date:2018-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1118225100000X
WAPT60919973225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist