1396091021 NPI number — LISA K LUCAS

Table of content: LISA K LUCAS (NPI 1396091021)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396091021 NPI number — LISA K LUCAS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LUCAS
Provider First Name:
LISA
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1396091021
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/18/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 MARTIN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHERRY HILL
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08002-2628
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-665-7800
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 E MORELAND RD
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
WILLOW GROVE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19090-4109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-784-9987
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/31/2012

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: 237700000X , with the licence number:  F03497 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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