Provider Demographics
NPI:1659476216
Name:LUCAS, DOUGLAS J (NP)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:J
Last Name:LUCAS
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:PO BOX 13550
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85216-3550
Mailing Address - Country:US
Mailing Address - Phone:480-325-3801
Mailing Address - Fax:480-325-3805
Practice Address - Street 1:6309 E BAYWOOD AVE
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-1744
Practice Address - Country:US
Practice Address - Phone:480-325-3801
Practice Address - Fax:480-325-3805
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN101467363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ922931Medicaid
AZ922931Medicaid