Provider Demographics
NPI:1790143980
Name:WAVRA, LUKAS (MOTR/L)
Entity Type:Individual
Prefix:MR
First Name:LUKAS
Middle Name:
Last Name:WAVRA
Suffix:
Gender:M
Credentials:MOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1109 LARK ST APT 104
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308-2332
Mailing Address - Country:US
Mailing Address - Phone:218-686-3426
Mailing Address - Fax:
Practice Address - Street 1:1020 LARK ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-2219
Practice Address - Country:US
Practice Address - Phone:320-759-5062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-03
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN104542225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN104542OtherMN OCCUPATIONAL THERAPY LICENSE
MN303564OtherNATIONAL BOARD FOR CERTIFICATIOM IN OCCUPATIONAL THERAPY, INC.