=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073911087
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LORENZEN LUCAS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/08/2014
-----------------------------------------------------
Last Update Date | 03/11/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 600 B ST
-----------------------------------------------------
City | LIVINGSTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95334-9593
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-850-3500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 600 B ST BLDG A
-----------------------------------------------------
City | LIVINGSTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95334-9593
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-850-3500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA09585
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA54129
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------