Provider Demographics
NPI:1790491298
Name:LUCERO, MICHAEL RUDOLPH (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:RUDOLPH
Last Name:LUCERO
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 1:1050 NOD ST
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37932-3717
Mailing Address - Country:US
Mailing Address - Phone:505-328-2236
Mailing Address - Fax:
Practice Address - Street 1:1050 NOD ST
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37932-3717
Practice Address - Country:US
Practice Address - Phone:505-328-2236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-27
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5375363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant