Provider Demographics
NPI:1558347682
Name:LUKE, GUILLERMINA M (PA-C)
Entity Type:Individual
Prefix:
First Name:GUILLERMINA
Middle Name:M
Last Name:LUKE
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 1:1412 WAUKEGAN RD
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60025-2121
Mailing Address - Country:US
Mailing Address - Phone:847-901-9840
Mailing Address - Fax:
Practice Address - Street 1:1412 WAUKEGAN RD
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60025-2121
Practice Address - Country:US
Practice Address - Phone:847-901-9840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-004921363AM0700X
AK1102363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO65332571Medicaid
COC496688Medicare PIN