Provider Demographics
NPI:1821067489
Name:LUCE, SERENA L (PA-C)
Entity Type:Individual
Prefix:
First Name:SERENA
Middle Name:L
Last Name:LUCE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SERENA
Other - Middle Name:A
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1648
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97440-1648
Mailing Address - Country:US
Mailing Address - Phone:541-686-1711
Mailing Address - Fax:541-686-6018
Practice Address - Street 1:1650 CHAMBERS ST
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97402-3636
Practice Address - Country:US
Practice Address - Phone:541-686-1711
Practice Address - Fax:541-686-6018
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005038794363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500652089Medicaid
1821067489OtherNPI
R167200Medicare PIN