Basic Information
| Provider Information | |||||||||
| NPI: | 1952573545 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LUCKY | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 863 | ||||||||
| Address2: | |||||||||
| City: | OZARK | ||||||||
| State: | AL | ||||||||
| PostalCode: | 363610863 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3347938087 | ||||||||
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| Practice Location | |||||||||
| Address1: | 126 HOSPITAL AVE | ||||||||
| Address2: | |||||||||
| City: | OZARK | ||||||||
| State: | AL | ||||||||
| PostalCode: | 363602018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3347938087 | ||||||||
| FaxNumber: | 3347938191 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2008 | ||||||||
| LastUpdateDate: | 01/21/2009 | ||||||||
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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 | 367500000X | 1-084888 | AL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 51044800 | 01 | AL | BCBS OF AL | OTHER | 1952573545 | 05 | AL | MEDICAID |