Basic Information
| Provider Information | |||||||||
| NPI: | 1386068955 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LUCCA | ||||||||
| FirstName: | ANTHONY | ||||||||
| MiddleName: | JARED | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1119 INTERLACKEN RD | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627042129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2176225975 | ||||||||
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| Practice Location | |||||||||
| Address1: | 701 N 1ST ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627810001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2177883156 | ||||||||
| FaxNumber: | 2177886459 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2014 | ||||||||
| LastUpdateDate: | 02/18/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.