Provider Demographics
NPI:1245787159
Name:PETTIT, LUCAS
Entity type:Individual
Prefix:
First Name:LUCAS
Middle Name:
Last Name:PETTIT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3292 BLACK ST
Mailing Address - Street 2:
Mailing Address - City:SCIPIO CENTER
Mailing Address - State:NY
Mailing Address - Zip Code:13147-3172
Mailing Address - Country:US
Mailing Address - Phone:315-406-6385
Mailing Address - Fax:
Practice Address - Street 1:8003 BREWERTON RD
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:NY
Practice Address - Zip Code:13039-9528
Practice Address - Country:US
Practice Address - Phone:315-288-4006
Practice Address - Fax:315-288-4760
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-08
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical