Healthcare Provider Details

I. General information

NPI: 1104241678
Provider Name (Legal Business Name): JENNIFER FOWLER LUCAS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2014
Last Update Date: 12/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20306 BADGER LANE
ONLEY VA
23418-0159
US

IV. Provider business mailing address

PO BOX 159
ONLEY VA
23418-0159
US

V. Phone/Fax

Practice location:
  • Phone: 757-787-7374
  • Fax: 757-787-4513
Mailing address:
  • Phone: 757-787-7374
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0110004450
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: