Healthcare Provider Details

I. General information

NPI: 1366542193
Provider Name (Legal Business Name): WILLIAM CLYDE LUCAS FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7640 W. MAVERICK RD.
SAHUARITA AZ
85629
US

IV. Provider business mailing address

PO BOX 1681
GREEN VALLEY AZ
85622-1681
US

V. Phone/Fax

Practice location:
  • Phone: 520-625-5853
  • Fax:
Mailing address:
  • Phone: 520-625-5853
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN 039777
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: