Lucas Martinus Suryakusuma, MPAS, PA-C
Physician Assistant in Dallas, TX. Individual provider (NPI-1).
NPI number1982252961
StatusActive
Last updated in NPPESApr 3, 2020
Details
- NPI
- 1982252961
- Entity type
- Individual (NPI-1)
- Name
- Lucas Martinus Suryakusuma
- Credential
- MPAS, PA-C
- Sex
- Male
- Sole proprietor
- No
- Enumeration date
- Sep 3, 2019
- Certification date
- Apr 3, 2020
- Last updated
- Apr 3, 2020
Medicare and OIG
- Medicare enrolled (PECOS)
- Yes · PRACTITIONER - PHYSICIAN ASSISTANT
- Can order and refer
- Part B Yes · DME Yes · Home health Yes · Power mobility Yes · Hospice No
- OIG exclusion list
- This NPI is not listed
CMS and OIG files of November 2026. PECOS lookup · OIG exclusion check
Taxonomy and licenses
| Taxonomy code | Description | License | State | Primary |
|---|---|---|---|---|
| 363A00000X | Physician Assistant | PA13328 | TX | Yes |
| 390200000X | Student in an Organized Health Care Education/Training Program | – | – |
Practice location
5323 Harry Hines Blvd Stop 7200Dallas, TX 75390-0001
Phone 214-648-1701
Mailing address
Po Box 845347Dallas, TX 75284-7208
Is something wrong?
This page shows exactly what the provider filed with NPPES. Only the provider (or their surrogate) can change it, by signing in to NPPES. Our page updates within a day of their change. See how to update NPI information.
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