Provider Demographics
NPI:1790018224
Name:LUKUS, MICHAEL JOSEPH (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:LUKUS
Suffix:
Gender:M
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 1:790 NORTHERN BLVD
Mailing Address - Street 2:SUITE K
Mailing Address - City:SOUTH ABINGTON TOWNSHIP
Mailing Address - State:PA
Mailing Address - Zip Code:18411-8799
Mailing Address - Country:US
Mailing Address - Phone:570-585-4141
Mailing Address - Fax:
Practice Address - Street 1:790 NORTHERN BLVD
Practice Address - Street 2:SUITE K
Practice Address - City:SOUTH ABINGTON TOWNSHIP
Practice Address - State:PA
Practice Address - Zip Code:18411-8799
Practice Address - Country:US
Practice Address - Phone:570-586-4141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-16
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA054092363AS0400X
PAOA002401363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00975601OtherRR MEDICARE
PA201270Medicare PIN