Healthcare Provider Details

I. General information

NPI: 1689275406
Provider Name (Legal Business Name): LUCAS PAUL MILLER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2020
Last Update Date: 11/06/2020
Certification Date: 11/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14555 LEVAN RD STE 309
LIVONIA MI
48154-5085
US

IV. Provider business mailing address

4930 BRIGHTON OAKS TRL
BRIGHTON MI
48116-9606
US

V. Phone/Fax

Practice location:
  • Phone: 734-462-5858
  • Fax: 734-462-5860
Mailing address:
  • Phone: 810-775-9410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601010286
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: