Provider Demographics
NPI:1467001701
Name:MARTIN, LUCAS JACOB (APRN)
Entity Type:Individual
Prefix:
First Name:LUCAS
Middle Name:JACOB
Last Name:MARTIN
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 MONTEREY DR
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32726-6413
Mailing Address - Country:US
Mailing Address - Phone:352-901-2207
Mailing Address - Fax:
Practice Address - Street 1:1310 MONTEREY DR
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-6413
Practice Address - Country:US
Practice Address - Phone:352-901-2207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-10
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11003891363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner