Basic Information
| Provider Information | |||||||||
| NPI: | 1225178734 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LUCAS | ||||||||
| FirstName: | WENDY | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4533 BRAMBLETON AVE | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240183436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5407728022 | ||||||||
| FaxNumber: | 5407720294 | ||||||||
| Practice Location | |||||||||
| Address1: | 109 KNOTBREAK RD | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | VA | ||||||||
| PostalCode: | 241535404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5407728022 | ||||||||
| FaxNumber: | 5407720294 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2007 | ||||||||
| LastUpdateDate: | 11/17/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2305002856 | VA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 249624 | 01 | VA | ANTHEM PT LOC 6 | OTHER | 193434 | 01 | VA | ANTHEM PT LOC 2 | OTHER | 193437 | 01 | VA | ANTHEM PT LOC 3 | OTHER | 193431 | 01 | VA | ANTHEM PT LOC 1 | OTHER | 193442 | 01 | VA | ANTHEM PT LOC 5 | OTHER |