=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205717212
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LUCAS ANDREW SMITH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/09/2025
-----------------------------------------------------
Last Update Date | 01/21/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6519 LITTLE RD
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28110-7092
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 980-721-1095
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18805 W CATAWBA AVE STE 205A
-----------------------------------------------------
City | CORNELIUS
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28031-4609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 5023822
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------