Healthcare Provider Details

I. General information

NPI: 1770928558
Provider Name (Legal Business Name): ALEXIS B DE LUCCA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ALEXIS B HANSEN

II. Dates (important events)

Enumeration Date: 05/07/2013
Last Update Date: 12/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 SE 182ND AVENUE
GRESHAM OR
97030
US

IV. Provider business mailing address

421 SW OAK ST STE. 210
PORTLAND OR
97204-1817
US

V. Phone/Fax

Practice location:
  • Phone: 503-988-5400
  • Fax: 503-988-5668
Mailing address:
  • Phone: 503-988-7468
  • Fax: 503-988-3015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD175758
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier096511
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer
# 2
Identifier022959
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: