Provider Demographics
NPI:1023787256
Name:LIPPERT, LUCAS
Entity type:Individual
Prefix:
First Name:LUCAS
Middle Name:
Last Name:LIPPERT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3526 WYOTA AVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53711-1741
Mailing Address - Country:US
Mailing Address - Phone:415-810-4602
Mailing Address - Fax:
Practice Address - Street 1:5833 AMERICAN PKWY
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53718-8325
Practice Address - Country:US
Practice Address - Phone:608-230-4681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-10
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15545-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist