Provider Demographics
NPI:1376920918
Name:MARTIN, LUCAS JOHN (PA)
Entity Type:Individual
Prefix:
First Name:LUCAS
Middle Name:JOHN
Last Name:MARTIN
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 1:2850 SE POWELL VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97080-1494
Mailing Address - Country:US
Mailing Address - Phone:503-666-5050
Mailing Address - Fax:
Practice Address - Street 1:4259 23RD AVE W
Practice Address - Street 2:SUITE 200
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98199-1534
Practice Address - Country:US
Practice Address - Phone:206-612-7869
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-04
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA169881363A00000X
WAPA 60516081363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant