Basic Information
| Provider Information | |||||||||
| NPI: | 1669030987 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LUCASAN | ||||||||
| FirstName: | DANAH MAJORIE | ||||||||
| MiddleName: | FERNANDO | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LUCASAN | ||||||||
| OtherFirstName: | DANAH | ||||||||
| OtherMiddleName: | FERNANDO | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | NP-C | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 10565 CIVIC CENTER DR BLDG SUITE165 | ||||||||
| Address2: | |||||||||
| City: | RANCHO CUCAMONGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917303853 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9099852211 | ||||||||
| FaxNumber: | 9099852244 | ||||||||
| Practice Location | |||||||||
| Address1: | 10565 CIVIC CENTER DR BLDG SUITE165 | ||||||||
| Address2: | |||||||||
| City: | RANCHO CUCAMONGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917303853 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9099852211 | ||||||||
| FaxNumber: | 9099852244 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2019 | ||||||||
| LastUpdateDate: | 08/20/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 95011876 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.