Healthcare Provider Details

I. General information

NPI: 1578111688
Provider Name (Legal Business Name): CARL VINCENT LUCAS NP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2019
Last Update Date: 03/31/2021
Certification Date: 03/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1542 S BLOOMINGTON ST
GREENCASTLE IN
46135-2212
US

IV. Provider business mailing address

5575 CRYSTAL BAY WEST DR
PLAINFIELD IN
46168-9259
US

V. Phone/Fax

Practice location:
  • Phone: 765-301-7300
  • Fax:
Mailing address:
  • Phone: 317-989-7879
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71009306A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: