Provider Demographics
NPI:1982976924
Name:LUCAS, ASHLEY (PA)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:LUCAS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:
Other - Last Name:COFFMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4069 LAKE DR SE
Practice Address - Street 2:SUITE 117
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8816
Practice Address - Country:US
Practice Address - Phone:616-267-8600
Practice Address - Fax:616-267-8605
Is Sole Proprietor?:No
Enumeration Date:2012-02-07
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC04685363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM74460853Medicare PIN
MI1982976924Medicaid