Healthcare Provider Details

I. General information

NPI: 1699111633
Provider Name (Legal Business Name): LUCAS ADAM SUTHERS APNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2013
Last Update Date: 10/10/2023
Certification Date: 10/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

731 CLAY ST
DARLINGTON WI
53530-1225
US

IV. Provider business mailing address

800 CLAY ST
DARLINGTON WI
53530-1228
US

V. Phone/Fax

Practice location:
  • Phone: 608-776-4497
  • Fax: 608-776-2837
Mailing address:
  • Phone: 608-776-4466
  • Fax: 608-776-5711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number195715-30
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number8070-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: