Provider Demographics
NPI:1568145688
Name:LUCAS, ERNEST JANRAE MANGABAT (PTA)
Entity Type:Individual
Prefix:
First Name:ERNEST JANRAE
Middle Name:MANGABAT
Last Name:LUCAS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9415 ATWOOD RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:ROSENBERG
Mailing Address - State:TX
Mailing Address - Zip Code:77469-1938
Mailing Address - Country:US
Mailing Address - Phone:361-816-3518
Mailing Address - Fax:
Practice Address - Street 1:18502 W BELLFORT ST STE 118
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77407-9003
Practice Address - Country:US
Practice Address - Phone:281-816-3528
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-08
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2178154225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant