Provider Demographics
NPI:1417521691
Name:LUCAS, SHAWNEE
Entity Type:Individual
Prefix:
First Name:SHAWNEE
Middle Name:
Last Name:LUCAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2826 FM 241 S
Mailing Address - Street 2:
Mailing Address - City:RUSK
Mailing Address - State:TX
Mailing Address - Zip Code:75785-5307
Mailing Address - Country:US
Mailing Address - Phone:256-520-0643
Mailing Address - Fax:
Practice Address - Street 1:2826 FM 241 S
Practice Address - Street 2:
Practice Address - City:RUSK
Practice Address - State:TX
Practice Address - Zip Code:75785-5307
Practice Address - Country:US
Practice Address - Phone:256-520-0643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-13
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXFPF00001171242T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes242T00000XTechnologists, Technicians & Other Technical Service ProvidersPerfusionistGroup - Single Specialty