Healthcare Provider Details

I. General information

NPI: 1205553773
Provider Name (Legal Business Name): LUCAS CRAFT PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2022
Last Update Date: 04/13/2026
Certification Date: 04/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20225 BOTHELL EVERETT HWY APT 331
BOTHELL WA
98012-8180
US

IV. Provider business mailing address

20225 BOTHELL EVERETT HWY APT 331
BOTHELL WA
98012-8180
US

V. Phone/Fax

Practice location:
  • Phone: 217-620-6221
  • Fax:
Mailing address:
  • Phone: 217-620-6221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number61443443
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: