Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 213E00000X | Podiatrist | ||
N | 222Z00000X | Podiatrist | ||
Y | 224P00000X | Prosthetist | ||
N | 225000000X | Orthotic Fitter |
NPI | 1588950653 |
---|---|
Provider Name | Lucas Broadhurst |
First Address | Tracy, CA 95304-9314 |
Second Address | Sacramento, CA 95816-5225 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/06/2011 |
Last Update Date | 10/01/2012 |