Healthcare Provider Details

I. General information

NPI: 1760429906
Provider Name (Legal Business Name): THOMAS DAVID LUKACSA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 04/22/2025
Certification Date: 04/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 HEALTH PARK BLVD
SAINT AUGUSTINE FL
32086-5776
US

IV. Provider business mailing address

PO BOX 100237
GAINESVILLE FL
32610-0237
US

V. Phone/Fax

Practice location:
  • Phone: 904-823-3401
  • Fax: 904-829-8649
Mailing address:
  • Phone: 352-392-4541
  • Fax: 352-294-8519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9104358
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: