Healthcare Provider Details

I. General information

NPI: 1770637209
Provider Name (Legal Business Name): EUGENE JOSEPH LUCERO PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 04/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 MAIN ST.
OLATHE CO
81425
US

IV. Provider business mailing address

PO BOX 529
OLATHE CO
81425-0529
US

V. Phone/Fax

Practice location:
  • Phone: 970-323-6141
  • Fax: 970-323-6117
Mailing address:
  • Phone: 970-323-6141
  • Fax: 970-323-6117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1068231
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: