Basic Information
| Provider Information | |||||||||
| NPI: | 1538190715 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LUCAS | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2914 S REPUBLIC BLVD | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436151912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195318808 | ||||||||
| FaxNumber: | 4195319342 | ||||||||
| Practice Location | |||||||||
| Address1: | 5200 HARROUN RD | ||||||||
| Address2: | |||||||||
| City: | SYLVANIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435602168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198241305 | ||||||||
| FaxNumber: | 4198241393 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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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 | 367500000X | RN139727 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 000000362701 | 01 | OH | ANTHEM | OTHER | 0768594 | 05 | OH | MEDICAID | 341877986019 | 01 | OH | MMOH | OTHER | 341877986020 | 01 | OH | MMOH | OTHER |