1225178734 NPI number — WENDY T LUCAS PT

Table of content: WENDY T LUCAS PT (NPI 1225178734)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225178734 NPI number — WENDY T LUCAS PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LUCAS
Provider First Name:
WENDY
Provider Middle Name:
T
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

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:
1225178734
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/17/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4533 BRAMBLETON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROANOKE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24018-3436
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-772-8022
Provider Business Mailing Address Fax Number:
540-772-0294

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
109 KNOTBREAK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALEM
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24153-5404
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-772-8022
Provider Business Practice Location Address Fax Number:
540-772-0294
Provider Enumeration Date:
02/07/2007

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:  2305002856 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 249624 . This is a "ANTHEM PT LOC 6" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 193434 . This is a "ANTHEM PT LOC 2" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 193437 . This is a "ANTHEM PT LOC 3" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 193431 . This is a "ANTHEM PT LOC 1" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 193442 . This is a "ANTHEM PT LOC 5" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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