Provider Demographics
NPI:1871668277
Name:LUCERO, PAUL DUARTE
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:DUARTE
Last Name:LUCERO
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 1:7036 S PETREL LN
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85706-8606
Mailing Address - Country:US
Mailing Address - Phone:520-806-1717
Mailing Address - Fax:
Practice Address - Street 1:7036 S PETREL LN
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85706-8606
Practice Address - Country:US
Practice Address - Phone:520-806-1717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ385HR2055X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ761256Medicaid