Provider Demographics
NPI:1255721320
Name:VANCE, LUCAS (PA)
Entity type:Individual
Prefix:
First Name:LUCAS
Middle Name:
Last Name:VANCE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13332 MIDLOTHIAN TPKE
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23113-4210
Mailing Address - Country:US
Mailing Address - Phone:804-794-5598
Mailing Address - Fax:
Practice Address - Street 1:13332 MIDLOTHIAN TPKE
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23113-4210
Practice Address - Country:US
Practice Address - Phone:804-794-5598
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-28
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0120022552255A2300X
VA0110007772363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer