Provider Demographics
NPI:1225541808
Name:PORTER, LUCAS (PA-C)
Entity Type:Individual
Prefix:
First Name:LUCAS
Middle Name:
Last Name:PORTER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 PALOMINO LN STE 110
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-4892
Mailing Address - Country:US
Mailing Address - Phone:702-474-7200
Mailing Address - Fax:702-474-0009
Practice Address - Street 1:2680 CRIMSON CANYON DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0841
Practice Address - Country:US
Practice Address - Phone:208-814-5075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-06
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDAT-5692255A2300X
363A00000X
NVPA2514363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer