Basic Information
| Provider Information | |||||||||
| NPI: | 1285821538 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LUKAS | ||||||||
| FirstName: | CAROL | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 38935 ANN ARBOR RD | ||||||||
| Address2: | CREDENTIALING/PAYER CONTRACTING | ||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481503397 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346320175 | ||||||||
| FaxNumber: | 7346320182 | ||||||||
| Practice Location | |||||||||
| Address1: | 18101 OAKWOOD BLVD | ||||||||
| Address2: | ISU-OBSERVATION UNIT | ||||||||
| City: | DEARBORN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481244089 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139825770 | ||||||||
| FaxNumber: | 3139825771 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2007 | ||||||||
| LastUpdateDate: | 03/19/2012 | ||||||||
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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 | 363L00000X | 4704208250 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 11904589 | 01 | CAQH | OTHER | 1285821538 | 05 | MI | MEDICAID |