Basic Information
| Provider Information | |||||||||
| NPI: | 1366580953 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCLUCAS | ||||||||
| FirstName: | DEBORAH | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MEDEIROS | ||||||||
| OtherFirstName: | DEBORAH | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 147 MILK ST FL 9 | ||||||||
| Address2: | PROVIDER ENROLLMENT | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021094806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175598374 | ||||||||
| FaxNumber: | 6174213487 | ||||||||
| Practice Location | |||||||||
| Address1: | 26 CITY HALL MALL | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021554754 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7813065100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2007 | ||||||||
| LastUpdateDate: | 07/31/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 1437 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.