Provider Demographics
NPI:1770278574
Name:BOLT, LUCAS (NP)
Entity type:Individual
Prefix:
First Name:LUCAS
Middle Name:
Last Name:BOLT
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:5255 E STOP 11 RD STE 200
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-6341
Practice Address - Country:US
Practice Address - Phone:317-528-1212
Practice Address - Fax:317-528-1252
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-07
Last Update Date:2023-04-10
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN71013689A363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health