Healthcare Provider Details

I. General information

NPI: 1629093851
Provider Name (Legal Business Name): GORDON H. LUCAS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 HIGHWAY 91 SOUTH
DILLON MT
59725-3516
US

IV. Provider business mailing address

PO BOX 34940
SEATTLE WA
98124-1940
US

V. Phone/Fax

Practice location:
  • Phone: 406-683-3000
  • Fax:
Mailing address:
  • Phone: 503-372-2740
  • Fax: 503-372-2754

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number29790
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: