Provider Demographics
NPI:1356804454
Name:LUCAS, JUSTIN ROLAND
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:ROLAND
Last Name:LUCAS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5221 PARAMOUNT PKWY STE 220
Mailing Address - Street 2:
Mailing Address - City:MORRISVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27560-5490
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2605 BLUE RIDGE RD STE 300
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-6475
Practice Address - Country:US
Practice Address - Phone:919-787-3448
Practice Address - Fax:919-232-0006
Is Sole Proprietor?:No
Enumeration Date:2019-04-08
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2023-01295207Q00000X
NC250421390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program