Provider Demographics
NPI:1114060746
Name:LUCERO, JULIE NEWMANN (PA-C)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:NEWMANN
Last Name:LUCERO
Suffix:
Gender:F
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 1:229 W STEWART AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-3663
Mailing Address - Country:US
Mailing Address - Phone:541-282-8808
Mailing Address - Fax:541-618-6452
Practice Address - Street 1:229 W STEWART AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-3663
Practice Address - Country:US
Practice Address - Phone:541-282-8808
Practice Address - Fax:541-618-6452
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00607207Q00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR5000637855Medicaid