Provider Demographics
NPI:1336486117
Name:WARREN, LUCAS WYATT (IDC)
Entity Type:Individual
Prefix:
First Name:LUCAS
Middle Name:WYATT
Last Name:WARREN
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1ST MARINE SPECIAL OPERATIONS BN. MEDICAL
Mailing Address - Street 2:BOX 555341
Mailing Address - City:FPO
Mailing Address - State:AA
Mailing Address - Zip Code:92055-5341
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1ST MARINE SPECIAL OPERATIONS BN. MEDICAL
Practice Address - Street 2:BOX 555341
Practice Address - City:FPO
Practice Address - State:AE
Practice Address - Zip Code:92055-5341
Practice Address - Country:US
Practice Address - Phone:760-725-6579
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-14
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman