Healthcare Provider Details

I. General information

NPI: 1477372985
Provider Name (Legal Business Name): ZACHARY LUCAS RN, NRP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2024
Last Update Date: 10/10/2024
Certification Date: 10/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 E NIZHONI BLVD
GALLUP NM
87301-5748
US

IV. Provider business mailing address

516 E NIZHONI BLVD
GALLUP NM
87301-5748
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code146L00000X
TaxonomyParamedic
License Number231630
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License NumberR056585
License Number StateSD
# 3
Primary TaxonomyN
Taxonomy Code163WF0300X
TaxonomyFlight Registered Nurse
License NumberR056585
License Number StateSD
# 4
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberR056585
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: