1023662830 NPI number — LOGAN A LUCAS PT

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023662830 NPI number — LOGAN A LUCAS PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LUCAS
Provider First Name:
LOGAN
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023662830
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/28/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11109 PARKVIEW PLAZA DR # 117
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46845-1701
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11143 PARKVIEW PLAZA DR STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46845-1728
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-266-7400
Provider Business Practice Location Address Fax Number:
260-266-7439
Provider Enumeration Date:
07/30/2019

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  05013336A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)