Healthcare Provider Details

I. General information

NPI: 1497634547
Provider Name (Legal Business Name): LUCAS B FADEM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2025
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3075 ADELINE ST STE 120
BERKELEY CA
94703-2579
US

IV. Provider business mailing address

4203 BROOKLYN AVE NE APT 95
SEATTLE WA
98105-5910
US

V. Phone/Fax

Practice location:
  • Phone: 510-621-7098
  • Fax: 510-848-4445
Mailing address:
  • Phone: 303-908-3676
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: