Provider Demographics
NPI:1295987410
Name:LUST, MICAH DANIELLE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:MICAH
Middle Name:DANIELLE
Last Name:LUST
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:7008 INDIANA AVE
Mailing Address - Street 2:STE. A
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79413-6114
Mailing Address - Country:US
Mailing Address - Phone:806-698-8088
Mailing Address - Fax:806-698-8588
Practice Address - Street 1:5004 122ND ST STE 200
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79424-8398
Practice Address - Country:US
Practice Address - Phone:469-734-8689
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-21
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXPA05964363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical