Provider Demographics
NPI:1902304041
Name:DELUCAS, JOHN STEPHEN (PA-C)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:STEPHEN
Last Name:DELUCAS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:517 STEELE LOOP
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28411-6208
Mailing Address - Country:US
Mailing Address - Phone:205-527-1275
Mailing Address - Fax:
Practice Address - Street 1:5214 MARKET ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28405-4067
Practice Address - Country:US
Practice Address - Phone:910-782-3284
Practice Address - Fax:910-796-8379
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-23
Last Update Date:2021-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-07952261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care