Provider Demographics
NPI:1922068808
Name:LUCAS, ANALISE KATHRYN (PA-C)
Entity Type:Individual
Prefix:MS
First Name:ANALISE
Middle Name:KATHRYN
Last Name:LUCAS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:J
Other - Last Name:GRADIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHYSICIAN ASSISTANT
Mailing Address - Street 1:P. O. BOX 787 - 0787
Mailing Address - Street 2:
Mailing Address - City:PERIDOT
Mailing Address - State:AZ
Mailing Address - Zip Code:85542
Mailing Address - Country:US
Mailing Address - Phone:928-475-1340
Mailing Address - Fax:928-474-7370
Practice Address - Street 1:103 MEDICINE WAY ROAD
Practice Address - Street 2:
Practice Address - City:PERIDOT
Practice Address - State:AZ
Practice Address - Zip Code:85542
Practice Address - Country:US
Practice Address - Phone:928-475-1340
Practice Address - Fax:928-475-7370
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3811363A00000X
AZ2510363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ624959Medicaid
AZMG0723660OtherDEA
CO792086Medicare PIN
AZMG0723660OtherDEA