Healthcare Provider Details

I. General information

NPI: 1386068955
Provider Name (Legal Business Name): ANTHONY JARED LUCCA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2014
Last Update Date: 02/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 N 1ST ST
SPRINGFIELD IL
62781-0001
US

IV. Provider business mailing address

1119 INTERLACKEN RD
SPRINGFIELD IL
62704-2129
US

V. Phone/Fax

Practice location:
  • Phone: 217-788-3156
  • Fax: 217-788-6459
Mailing address:
  • Phone: 217-622-5975
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: