Provider Demographics
NPI:1265817779
Name:HUBBARD, LUKE
Entity Type:Individual
Prefix:
First Name:LUKE
Middle Name:
Last Name:HUBBARD
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 1:2059 DERWIN CIR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MO
Mailing Address - Zip Code:63755-8551
Mailing Address - Country:US
Mailing Address - Phone:573-979-1491
Mailing Address - Fax:
Practice Address - Street 1:1701 LACEY ST
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-5230
Practice Address - Country:US
Practice Address - Phone:573-651-5562
Practice Address - Fax:573-651-5868
Is Sole Proprietor?:No
Enumeration Date:2015-07-26
Last Update Date:2016-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010003635163W00000X
MO110038367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse