Provider Demographics
NPI:1396946158
Name:LUCAS, ROBERT JAMES (MPAS PAC)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:JAMES
Last Name:LUCAS
Suffix:
Gender:M
Credentials:MPAS PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 OLD KINGS HIGHWAY SOUTH
Mailing Address - Street 2:A & M SURGERY
Mailing Address - City:DARIEN
Mailing Address - State:CT
Mailing Address - Zip Code:06820
Mailing Address - Country:US
Mailing Address - Phone:203-656-0402
Mailing Address - Fax:203-656-4467
Practice Address - Street 1:17 OLD KINGS HIGHWAY SOUTH
Practice Address - Street 2:A & M SURGERY
Practice Address - City:DARIEN
Practice Address - State:CT
Practice Address - Zip Code:06820
Practice Address - Country:US
Practice Address - Phone:203-656-0402
Practice Address - Fax:203-656-4467
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000371363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1013289OtherNCCPA
CT000371OtherDEPT HEALTH LICENSE