Provider Demographics
NPI:1386824944
Name:LUCAS, STACY RYAN (LPTA, LMT)
Entity Type:Individual
Prefix:MR
First Name:STACY
Middle Name:RYAN
Last Name:LUCAS
Suffix:
Gender:M
Credentials:LPTA, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 LINCOLN DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-2304
Mailing Address - Country:US
Mailing Address - Phone:304-768-4400
Mailing Address - Fax:
Practice Address - Street 1:1000 LINCOLN DR
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-2304
Practice Address - Country:US
Practice Address - Phone:304-768-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-11
Last Update Date:2007-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV000627225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant