Provider Demographics
NPI:1619226438
Name:FUSSELL, LUCAS ALLEN (NP)
Entity Type:Individual
Prefix:
First Name:LUCAS
Middle Name:ALLEN
Last Name:FUSSELL
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20306 BADGER LANE
Mailing Address - Street 2:
Mailing Address - City:ONLEY
Mailing Address - State:VA
Mailing Address - Zip Code:23418-0159
Mailing Address - Country:US
Mailing Address - Phone:757-787-7374
Mailing Address - Fax:757-787-4581
Practice Address - Street 1:20306 BADGER LANE
Practice Address - Street 2:
Practice Address - City:ONLEY
Practice Address - State:VA
Practice Address - Zip Code:23418-0159
Practice Address - Country:US
Practice Address - Phone:757-787-7374
Practice Address - Fax:757-787-4581
Is Sole Proprietor?:No
Enumeration Date:2012-09-07
Last Update Date:2014-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024170248363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily