Provider Demographics
NPI:1760518179
Name:EADS, LUCY (PA)
Entity Type:Individual
Prefix:
First Name:LUCY
Middle Name:
Last Name:EADS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1963 N E ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92405-3919
Mailing Address - Country:US
Mailing Address - Phone:909-881-6146
Mailing Address - Fax:909-881-3479
Practice Address - Street 1:1278 E LATHAM AVE
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92543-4445
Practice Address - Country:US
Practice Address - Phone:951-925-6625
Practice Address - Fax:951-658-0775
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAPA18333363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program