Basic Information
| Provider Information | |||||||||
| NPI: | 1649222837 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LUCE | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | WAYNE | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3201 W HIGHWAY 22 | ||||||||
| Address2: | |||||||||
| City: | CORSICANA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 751102450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9036546800 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3201 W HIGHWAY 22 | ||||||||
| Address2: | |||||||||
| City: | CORSICANA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 751102450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9036546800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 04/15/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 2815838 | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 727861 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 000000378049 | 01 | IN | SIA'S | OTHER | 193593402 | 05 | TX | MEDICAID | 200528760 | 05 | IN | MEDICAID | 88083U | 01 | TX | BCBS | OTHER |