Provider Demographics
NPI:1033879739
Name:LUU, HENRY C
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:C
Last Name:LUU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17612 17TH ST STE 101
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-1962
Mailing Address - Country:US
Mailing Address - Phone:714-243-5450
Mailing Address - Fax:
Practice Address - Street 1:17612 17TH ST STE 101
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-1962
Practice Address - Country:US
Practice Address - Phone:714-243-5450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-21
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA60523363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant