Healthcare Provider Details

I. General information

NPI: 1831116466
Provider Name (Legal Business Name): JAMES W LUST P.A.-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 10/31/2023
Certification Date: 10/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1095 S BRADFORD ST
DOVER DE
19904-4141
US

IV. Provider business mailing address

1095 S BRADFORD ST
DOVER DE
19904-4141
US

V. Phone/Fax

Practice location:
  • Phone: 302-678-8100
  • Fax:
Mailing address:
  • Phone: 302-678-8100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC5-0000141
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: