MEDICARE: LUCAS JOHN MARTIN PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA169881	OR
2	363A00000X	Physician Assistant	PA 60516081	WA

General Provider Information

NPI Number	:	1376920918
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LUCAS JOHN MARTIN PA

Provider Business Mailing Address
First Line	:	2850 SE POWELL VALLEY RD
Second Line	:
City	:	GRESHAM
State	:	OR
Zip	:	97080-1494
Country	:	US
Telephone Number	:	503-666-5050
Fax Number	:

Provider Business Practice Location Address
First Line	:	4259 23RD AVE W
Second Line	:	SUITE 200
City	:	SEATTLE
State	:	WA
Zip	:	98199-1534
Country	:	US
Telephone Number	:	206-612-7869
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/04/2015
Last Update Date	:	04/29/2020

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Directions to “ LUCAS JOHN MARTIN PA” Practice Location

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