Healthcare Provider Details

I. General information

NPI: 1699522706
Provider Name (Legal Business Name): LUCAS CAMPBELL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2024
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1880 N FRONTAGE RD
HASTINGS MN
55033-2687
US

IV. Provider business mailing address

PO BOX 43
MINNEAPOLIS MN
55440-0043
US

V. Phone/Fax

Practice location:
  • Phone: 651-438-1800
  • Fax:
Mailing address:
  • Phone: 651-438-1800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number15532
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: