Provider Demographics
NPI:1417519257
Name:TEBBE, LUCAS SAMUEL (DPM)
Entity Type:Individual
Prefix:DR
First Name:LUCAS
Middle Name:SAMUEL
Last Name:TEBBE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11331 N STATE HIGHWAY V
Mailing Address - Street 2:
Mailing Address - City:WALNUT GROVE
Mailing Address - State:MO
Mailing Address - Zip Code:65770-8412
Mailing Address - Country:US
Mailing Address - Phone:417-988-9289
Mailing Address - Fax:
Practice Address - Street 1:7900 LEES SUMMIT RD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64139-1236
Practice Address - Country:US
Practice Address - Phone:816-404-9597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-02
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019024623213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery