Provider Demographics
NPI:1275934580
Name:LUCKEL, GILBERT LYNN JR (AG-ACNP)
Entity Type:Individual
Prefix:MR
First Name:GILBERT
Middle Name:LYNN
Last Name:LUCKEL
Suffix:JR
Gender:M
Credentials:AG-ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-579-5180
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:101 COURTENAY CIR
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-3176
Practice Address - Country:US
Practice Address - Phone:601-579-5180
Practice Address - Fax:601-579-5374
Is Sole Proprietor?:No
Enumeration Date:2014-09-06
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR884250363L00000X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01001724Medicaid
MS374159YKFFMedicare PIN