Provider Demographics
NPI:1649993023
Name:CORBIN, LUCAS SCOTT
Entity type:Individual
Prefix:
First Name:LUCAS
Middle Name:SCOTT
Last Name:CORBIN
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 1:1865 LPGA BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-7108
Mailing Address - Country:US
Mailing Address - Phone:386-255-4596
Mailing Address - Fax:386-258-3561
Practice Address - Street 1:1865 LPGA BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-7108
Practice Address - Country:US
Practice Address - Phone:386-255-4596
Practice Address - Fax:386-258-3561
Is Sole Proprietor?:No
Enumeration Date:2022-09-21
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9118565363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL122115600Medicaid