Provider Demographics
NPI:1013625359
Name:BURG, LUCAS (DPT)
Entity Type:Individual
Prefix:
First Name:LUCAS
Middle Name:
Last Name:BURG
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:186 SNOW GOOSE RD
Mailing Address - Street 2:
Mailing Address - City:LEWISTOWN
Mailing Address - State:MT
Mailing Address - Zip Code:59457-7692
Mailing Address - Country:US
Mailing Address - Phone:406-366-4210
Mailing Address - Fax:
Practice Address - Street 1:186 SNOW GOOSE RD
Practice Address - Street 2:
Practice Address - City:LEWISTOWN
Practice Address - State:MT
Practice Address - Zip Code:59457-7692
Practice Address - Country:US
Practice Address - Phone:406-366-4210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-07
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPTP-PT-LIC-24663225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist