Healthcare Provider Details

I. General information

NPI: 1669870929
Provider Name (Legal Business Name): LUCAS WILLOUGHBY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2014
Last Update Date: 02/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9263 MEDICAL PLAZA DR STE E
CHARLESTON SC
29406-7112
US

IV. Provider business mailing address

9263 MEDICAL PLAZA DR STE E
CHARLESTON SC
29406-7112
US

V. Phone/Fax

Practice location:
  • Phone: 843-572-1228
  • Fax: 843-576-6168
Mailing address:
  • Phone: 843-572-1228
  • Fax: 843-576-6168

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number106598
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number19279
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: