Provider Demographics
NPI:1548678055
Name:LUCZAK, ANTHONY (APRN)
Entity type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:
Last Name:LUCZAK
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:806 JEFFERSON TER
Mailing Address - Street 2:
Mailing Address - City:NEW IBERIA
Mailing Address - State:LA
Mailing Address - Zip Code:70560-5727
Mailing Address - Country:US
Mailing Address - Phone:337-365-4945
Mailing Address - Fax:337-367-3917
Practice Address - Street 1:1002 12TH ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70501-6224
Practice Address - Country:US
Practice Address - Phone:337-534-0107
Practice Address - Fax:337-534-0184
Is Sole Proprietor?:No
Enumeration Date:2014-07-28
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAPO7963363LP0200X
LAAP07963363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2374451Medicaid