Provider Demographics
NPI:1275174724
Name:LUGO, VICTORIA L (PA-C)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:L
Last Name:LUGO
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 1:234 5TH AVE
Mailing Address - Street 2:SUITE #412
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001-7607
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:234 5TH AVE
Practice Address - Street 2:SUITE #412
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-7607
Practice Address - Country:US
Practice Address - Phone:212-931-6220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-07
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NY024579363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104544500Medicaid