Provider Demographics
NPI:1861856601
Name:LU, KEPENG (PA)
Entity Type:Individual
Prefix:
First Name:KEPENG
Middle Name:
Last Name:LU
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 CONGRESSIONAL CT
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89113-1333
Mailing Address - Country:US
Mailing Address - Phone:702-858-3188
Mailing Address - Fax:
Practice Address - Street 1:2995 S JONES BLVD STE A
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-5612
Practice Address - Country:US
Practice Address - Phone:702-805-1880
Practice Address - Fax:702-805-1880
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-07
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA1731363A00000X
NVPA0334363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant