Provider Demographics
NPI:1023409802
Name:LUCAK, ALEXANDRA LYNN (PA-C)
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:LYNN
Last Name:LUCAK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9500 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44195-1913
Mailing Address - Country:US
Mailing Address - Phone:216-444-2200
Mailing Address - Fax:
Practice Address - Street 1:5800 COOPER FOSTER PARK RD W
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053-4131
Practice Address - Country:US
Practice Address - Phone:440-204-7800
Practice Address - Fax:440-204-7480
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-14
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.004267363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3025372Medicaid
OHH062060Medicare PIN
OHH072820Medicare PIN
OH9376891Medicare PIN
OH9389631Medicare PIN