Basic Information
| Provider Information | |||||||||
| NPI: | 1518046879 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LUCAS | ||||||||
| FirstName: | KATHRYN | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CNM | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LUCAS | ||||||||
| OtherFirstName: | KATHY | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | CNM | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 2198 | ||||||||
| Address2: | |||||||||
| City: | FORT DEFIANCE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 865042198 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287295231 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | FORT DEFIANCE PHS HOSPITAL | ||||||||
| Address2: | CORNER OF RT N12 AND N7 | ||||||||
| City: | FORT DEFIANCE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287298770 | ||||||||
| FaxNumber: | 9287298804 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 367A00000X | 513 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 02880580 | 05 | NM | MEDICAID | 840620 | 01 | AZ | AHCCCS | OTHER |