Healthcare Provider Details

I. General information

NPI: 1316306723
Provider Name (Legal Business Name): JOHN M LUCAS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2016
Last Update Date: 10/24/2022
Certification Date: 10/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 STANAFORD RD ANESTHESIA DEPARTMENT
BECKLEY WV
25801
US

IV. Provider business mailing address

113 PINE LN
MORGANTOWN WV
26508-8827
US

V. Phone/Fax

Practice location:
  • Phone: 304-255-3246
  • Fax:
Mailing address:
  • Phone: 304-641-5484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number76057
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAC002240
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: