Healthcare Provider Details

I. General information

NPI: 1649890252
Provider Name (Legal Business Name): LUCAS MICHAEL GASPARD PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2020
Last Update Date: 04/23/2020
Certification Date: 04/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12617 RIDGELINE BLVD BLDG C105
CEDAR PARK TX
78613-1606
US

IV. Provider business mailing address

4301 GRAND AVENUE PKWY APT 3318
AUSTIN TX
78728-0035
US

V. Phone/Fax

Practice location:
  • Phone: 512-996-0441
  • Fax:
Mailing address:
  • Phone: 361-649-0137
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1320849
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: