Provider Demographics
NPI:1538190715
Name:LUCAS, MARY C (CRNA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:LUCAS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2914 S REPUBLIC BLVD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43615-1912
Mailing Address - Country:US
Mailing Address - Phone:419-531-8808
Mailing Address - Fax:419-531-9342
Practice Address - Street 1:5200 HARROUN RD
Practice Address - Street 2:
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560-2168
Practice Address - Country:US
Practice Address - Phone:419-824-1305
Practice Address - Fax:419-824-1393
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN139727367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000362701OtherANTHEM
OH0768594Medicaid
OH341877986019OtherMMOH
OH341877986020OtherMMOH
OH0768594Medicaid
OHLU8229622Medicare ID - Type UnspecifiedOHIO MEDICARE