Basic Information
| Provider Information | |||||||||
| NPI: | 1255732798 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LUCAS | ||||||||
| FirstName: | MARY VIRGINIA | ||||||||
| MiddleName: | GIRARDEAU | ||||||||
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| Credential: | APRN, FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2030 POWERS FERRY RD SE | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303392823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6788012313 | ||||||||
| FaxNumber: | 8442492637 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 WITSELL ST | ||||||||
| Address2: | |||||||||
| City: | WALTERBORO | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294883052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435495546 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2014 | ||||||||
| LastUpdateDate: | 10/07/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 19050 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.