Basic Information
| Provider Information | |||||||||
| NPI: | 1821022120 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LUCAS | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1917 N LAKEWOOD DR | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838142634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086648194 | ||||||||
| FaxNumber: | 2086671847 | ||||||||
| Practice Location | |||||||||
| Address1: | 1917 N LAKEWOOD DR | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838142634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086648194 | ||||||||
| FaxNumber: | 2086671847 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 03/06/2009 | ||||||||
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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 | 225100000X | PT-1931 | ID | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 000010150822 | 01 | ID | BLUE SHIELD | OTHER | 0198312 | 01 | WA | LABOR AND INDUSTRY | OTHER | TC811 | 01 | ID | BLUE CROSS | OTHER | 807206500 | 05 | ID | MEDICAID |