Provider Demographics
NPI:1629685177
Name:CHRISTOFFERSEN, LUCUS CRAIG WEBB (NP)
Entity Type:Individual
Prefix:
First Name:LUCUS
Middle Name:CRAIG WEBB
Last Name:CHRISTOFFERSEN
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 1:4403 HARRISON BLVD STE 2815
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-3326
Mailing Address - Country:US
Mailing Address - Phone:801-387-7880
Mailing Address - Fax:
Practice Address - Street 1:4403 HARRISON BLVD STE 2815
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-3326
Practice Address - Country:US
Practice Address - Phone:801-387-7880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-29
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7367561-4405363LA2100X
VA0024182684363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner