Provider Demographics
NPI:1528215746
Name:VIRES, LUKE ANTON (COTA)
Entity Type:Individual
Prefix:MR
First Name:LUKE
Middle Name:ANTON
Last Name:VIRES
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10730 W CAMPBELL AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85037-5400
Mailing Address - Country:US
Mailing Address - Phone:623-772-2580
Mailing Address - Fax:
Practice Address - Street 1:10730 W CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037-5400
Practice Address - Country:US
Practice Address - Phone:623-772-2580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-19
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4202390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program