Provider Demographics
NPI:1922205152
Name:KERANEN, LUCAS JOHN (ATC)
Entity Type:Individual
Prefix:MR
First Name:LUCAS
Middle Name:JOHN
Last Name:KERANEN
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52808 WILD HAVEN RD
Mailing Address - Street 2:
Mailing Address - City:BRUNO
Mailing Address - State:MN
Mailing Address - Zip Code:55712-3082
Mailing Address - Country:US
Mailing Address - Phone:320-838-1432
Mailing Address - Fax:
Practice Address - Street 1:86032 COUNTY HIGHWAY 61
Practice Address - Street 2:
Practice Address - City:WILLOW RIVER
Practice Address - State:MN
Practice Address - Zip Code:55795-3216
Practice Address - Country:US
Practice Address - Phone:218-372-3101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN15502255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer