Provider Demographics
NPI:1326015892
Name:LUCKY, CORIANNA (PA-C)
Entity Type:Individual
Prefix:
First Name:CORIANNA
Middle Name:
Last Name:LUCKY
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 1:26901 BEAUMONT BLVD # 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:947-522-1952
Mailing Address - Fax:947-522-0307
Practice Address - Street 1:44201 DEQUINDRE RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48085-1117
Practice Address - Country:US
Practice Address - Phone:248-964-4866
Practice Address - Fax:248-964-4848
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004155363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIQ15650Medicare UPIN
MI0N33470081Medicare ID - Type Unspecified