Healthcare Provider Details

I. General information

NPI: 1558795393
Provider Name (Legal Business Name): TRAVIS DALE LUKASIK CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2013
Last Update Date: 05/29/2024
Certification Date: 05/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2131 S 17TH ST
WILMINGTON NC
28401-7407
US

IV. Provider business mailing address

2131 S 17TH ST
WILMINGTON NC
28401-7407
US

V. Phone/Fax

Practice location:
  • Phone: 910-772-9202
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number100961
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: