Provider Demographics
NPI:1205119831
Name:KNOWLTON, LUCAS (PA-C)
Entity type:Individual
Prefix:
First Name:LUCAS
Middle Name:
Last Name:KNOWLTON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:LUKE
Other - Middle Name:
Other - Last Name:KNOWLTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4720 S I 10 SERVICE RD W STE 301
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70001-1241
Mailing Address - Country:US
Mailing Address - Phone:504-885-8225
Mailing Address - Fax:504-885-7642
Practice Address - Street 1:4720 S I 10 SERVICE RD W STE 301
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70001-1241
Practice Address - Country:US
Practice Address - Phone:504-885-8225
Practice Address - Fax:504-885-7642
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-20
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4970363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAPA.200603OtherLA STATE BOARD OF MEDICAL EXAMINERS