Provider Demographics
NPI:1720549413
Name:MICHALIK, LUCAS
Entity Type:Individual
Prefix:
First Name:LUCAS
Middle Name:
Last Name:MICHALIK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5201 SHERMAN ST APT 2
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-8447
Mailing Address - Country:US
Mailing Address - Phone:715-305-8514
Mailing Address - Fax:
Practice Address - Street 1:111 DEHNE DR
Practice Address - Street 2:
Practice Address - City:COLBY
Practice Address - State:WI
Practice Address - Zip Code:54421-9581
Practice Address - Country:US
Practice Address - Phone:715-223-2331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-26
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1163388363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program