1871868208 NPI number — MS. JULIE A LUCKMAN

Table of content: MS. JULIE A LUCKMAN (NPI 1871868208)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871868208 NPI number — MS. JULIE A LUCKMAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LUCKMAN
Provider First Name:
JULIE
Provider Middle Name:
A
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LUCKMAN-WILCOX
Provider Other First Name:
JULIE
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PHYSICIAN ASSISTANT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1871868208
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/16/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
571 SAINT JOSEPHS BLVD
Provider Second Line Business Mailing Address:
FL 2
Provider Business Mailing Address City Name:
ELMIRA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14901-3230
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
607-271-2050
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2977 WESTINGHOUSE RD
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
HORSEHEADS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14845-8120
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
607-873-1832
Provider Business Practice Location Address Fax Number:
607-873-1833
Provider Enumeration Date:
03/19/2012

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:  015194-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 04403196 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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