Provider Demographics
NPI:1639908122
Name:JUDSON, LUCAS ALEXANDER
Entity type:Individual
Prefix:
First Name:LUCAS
Middle Name:ALEXANDER
Last Name:JUDSON
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 1:4018 N MISSISSIPPI AVE APT 212
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1698
Mailing Address - Country:US
Mailing Address - Phone:503-939-0715
Mailing Address - Fax:
Practice Address - Street 1:2236 SE BELMONT ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-2817
Practice Address - Country:US
Practice Address - Phone:503-445-7699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-31
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program