Provider Demographics
NPI:1790756898
Name:LUCAS, SHANNON DEAN (FNP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:DEAN
Last Name:LUCAS
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3619 11TH ST
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77705-9233
Mailing Address - Country:US
Mailing Address - Phone:409-749-0377
Mailing Address - Fax:
Practice Address - Street 1:3345 PLAZA 10 DR
Practice Address - Street 2:SUITE E
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77707-2554
Practice Address - Country:US
Practice Address - Phone:409-838-2626
Practice Address - Fax:409-838-1980
Is Sole Proprietor?:No
Enumeration Date:2006-01-28
Last Update Date:2007-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX629586363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX146102201Medicaid
TXP39196Medicare UPIN
TX86N335Medicare ID - Type Unspecified