Basic Information
| Provider Information | |||||||||
| NPI: | 1013323443 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | CHRISTENSEN | ||||||||
| FirstName: | LUCAS | ||||||||
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| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4631 WHITMAN LN SE | ||||||||
| Address2: | STE D | ||||||||
| City: | LACEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985132250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302962223 | ||||||||
| FaxNumber: | 6307599510 | ||||||||
| Practice Location | |||||||||
| Address1: | 3048 E BASELINE RD | ||||||||
| Address2: | SUITE 125 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852047286 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4802220655 | ||||||||
| FaxNumber: | 4802221457 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2014 | ||||||||
| LastUpdateDate: | 07/15/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 10982 | AZ | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 946863 | 05 | AZ | MEDICAID |