Provider Demographics
NPI:1083370191
Name:HUMMEL, JACOB LUKE (PA-C)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:LUKE
Last Name:HUMMEL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 S PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:NANTICOKE
Mailing Address - State:PA
Mailing Address - Zip Code:18634-2456
Mailing Address - Country:US
Mailing Address - Phone:570-735-7590
Mailing Address - Fax:
Practice Address - Street 1:121 S PROSPECT ST
Practice Address - Street 2:
Practice Address - City:NANTICOKE
Practice Address - State:PA
Practice Address - Zip Code:18634-2456
Practice Address - Country:US
Practice Address - Phone:570-735-7590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-12
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA062957363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant