Provider Demographics
NPI:1831877992
Name:LUCAS, MARIE ELIZABETH (PA-C)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:ELIZABETH
Last Name:LUCAS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 BROAD ST APT 10D
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10004-2522
Mailing Address - Country:US
Mailing Address - Phone:440-954-2316
Mailing Address - Fax:
Practice Address - Street 1:110 W 97TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-6450
Practice Address - Country:US
Practice Address - Phone:212-749-1820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-10
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY030844363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program