Provider Demographics
NPI:1558014175
Name:LUKOSE, JENNY (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:
Last Name:LUKOSE
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 1:7710 262ND ST
Mailing Address - Street 2:
Mailing Address - City:FLORAL PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11004-1344
Mailing Address - Country:US
Mailing Address - Phone:917-796-7776
Mailing Address - Fax:
Practice Address - Street 1:8000 UTOPIA PKWY
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11439-1344
Practice Address - Country:US
Practice Address - Phone:917-796-7776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-02
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027852-01363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant