Provider Demographics
NPI:1487927257
Name:WANGERIN, LUCAS M (PA-C)
Entity type:Individual
Prefix:
First Name:LUCAS
Middle Name:M
Last Name:WANGERIN
Suffix:
Gender:M
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 1:6382 SAN MATEO DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80911-4015
Mailing Address - Country:US
Mailing Address - Phone:785-226-2322
Mailing Address - Fax:
Practice Address - Street 1:1650 COCHRANE CIR # B7500
Practice Address - Street 2:
Practice Address - City:FORT CARSON
Practice Address - State:CO
Practice Address - Zip Code:80913-4604
Practice Address - Country:US
Practice Address - Phone:719-524-7219
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-09
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0007051363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
COPA.0007051Medicaid