Provider Demographics
NPI:1508619438
Name:LUK, JACQUELINE (PA)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:LUK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 E 31ST ST APT 22
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-6825
Mailing Address - Country:US
Mailing Address - Phone:646-575-0715
Mailing Address - Fax:
Practice Address - Street 1:30 E 31ST ST APT 22
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-6825
Practice Address - Country:US
Practice Address - Phone:646-575-0715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-10
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00839600363A00000X
NY031678363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant