Provider Demographics
NPI:1891255998
Name:LUPAS, LUCIAN I (PA-C)
Entity Type:Individual
Prefix:
First Name:LUCIAN
Middle Name:I
Last Name:LUPAS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21734 ALBION AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48336-5604
Mailing Address - Country:US
Mailing Address - Phone:248-895-1278
Mailing Address - Fax:
Practice Address - Street 1:21734 ALBION AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48336-5604
Practice Address - Country:US
Practice Address - Phone:248-895-1278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-23
Last Update Date:2019-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1139591363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant