Provider Demographics
NPI:1639827033
Name:MOSAIC MEDICINE, PLLC
Entity Type:Organization
Organization Name:MOSAIC MEDICINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CORY
Authorized Official - Middle Name:
Authorized Official - Last Name:LUCAS
Authorized Official - Suffix:
Authorized Official - Credentials:NP-C, ENP
Authorized Official - Phone:703-677-1035
Mailing Address - Street 1:11161 STATE ROAD 70 E UNIT 110-876
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD RANCH
Mailing Address - State:FL
Mailing Address - Zip Code:34202-9407
Mailing Address - Country:US
Mailing Address - Phone:703-677-1035
Mailing Address - Fax:
Practice Address - Street 1:11161 STATE ROAD 70 E UNIT 110-876
Practice Address - Street 2:
Practice Address - City:LAKEWOOD RANCH
Practice Address - State:FL
Practice Address - Zip Code:34202-9407
Practice Address - Country:US
Practice Address - Phone:703-677-1035
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-15
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty