Provider Demographics
NPI:1760976831
Name:LUCAS, KATHRYN AMELIA (DO)
Entity Type:Individual
Prefix:MISS
First Name:KATHRYN
Middle Name:AMELIA
Last Name:LUCAS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:5501 OLD YORK RD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19141-3018
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 W 16TH ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2781
Practice Address - Country:US
Practice Address - Phone:719-584-4306
Practice Address - Fax:719-595-7886
Is Sole Proprietor?:No
Enumeration Date:2018-06-21
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT018677207P00000X
CODR.0068474207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000207320Medicaid