Provider Demographics
NPI:1770291080
Name:GODWIN, LUCAS SHANE (SFIDC)
Entity type:Individual
Prefix:
First Name:LUCAS
Middle Name:SHANE
Last Name:GODWIN
Suffix:
Gender:M
Credentials:SFIDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 466 BOX 3
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96595-0001
Mailing Address - Country:US
Mailing Address - Phone:315-370-4232
Mailing Address - Fax:
Practice Address - Street 1:PSC 466 BX 3
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96595-0001
Practice Address - Country:US
Practice Address - Phone:315-370-4232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-07
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1710I1002X
ZZ17702910801710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman