1821067489 NPI number — SERENA L LUCE PA-C

Table of content: SERENA L LUCE PA-C (NPI 1821067489)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821067489 NPI number — SERENA L LUCE PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LUCE
Provider First Name:
SERENA
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LEE
Provider Other First Name:
SERENA
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1821067489
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/09/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1648
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EUGENE
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97440-1648
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-686-1711
Provider Business Mailing Address Fax Number:
541-686-6018

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1650 CHAMBERS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EUGENE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97402-3636
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-686-1711
Provider Business Practice Location Address Fax Number:
541-686-6018
Provider Enumeration Date:
03/16/2006

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: 363A00000X , with the licence number:  2005038794 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 500652089 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1821067489 . This is a "NPI" identifier . This identifiers is of the category "OTHER".




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