1104854694 NPI number — PAMELA LUSK NP

Table of content: PAMELA LUSK NP (NPI 1104854694)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104854694 NPI number — PAMELA LUSK NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LUSK
Provider First Name:
PAMELA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104854694
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/16/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
718 SOLANO DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PRESCOTT
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86301-1520
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-830-7530
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 N 3RD ST # MC2104
Provider Second Line Business Practice Location Address:
NP HEALTHCARE- DOWNTOWN PHOENIX CAMPUS
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85004-2135
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-496-0721
Provider Business Practice Location Address Fax Number:
602-496-0675
Provider Enumeration Date:
06/30/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X , with the licence number:  RN054820 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0808X , with the licence number: AP1313 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 953358 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".