Provider Demographics
NPI:1407524416
Name:LADDEN, LUCIS (PA-C)
Entity Type:Individual
Prefix:
First Name:LUCIS
Middle Name:
Last Name:LADDEN
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 1:1021 KENILWORTH AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44113-4422
Mailing Address - Country:US
Mailing Address - Phone:419-348-5807
Mailing Address - Fax:
Practice Address - Street 1:19 SUMMERHAVEN RD
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45440-3624
Practice Address - Country:US
Practice Address - Phone:419-348-5807
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-03
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.006983363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant