Provider Demographics
NPI:1912513854
Name:KLUCAS, CHRISTOPHER DAVID
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:DAVID
Last Name:KLUCAS
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 1:2313 E SAINT FRANCIS ST
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57703-5968
Mailing Address - Country:US
Mailing Address - Phone:605-222-4225
Mailing Address - Fax:
Practice Address - Street 1:1303 N LACROSSE ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-6956
Practice Address - Country:US
Practice Address - Phone:605-755-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-16
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1258363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant