Provider Demographics
NPI:1871868208
Name:LUCKMAN, JULIE A
Entity Type:Individual
Prefix:MS
First Name:JULIE
Middle Name:A
Last Name:LUCKMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:JULIE
Other - Middle Name:A
Other - Last Name:LUCKMAN-WILCOX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHYSICIAN ASSISTANT
Mailing Address - Street 1:571 SAINT JOSEPHS BLVD
Mailing Address - Street 2:FL 2
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14901-3230
Mailing Address - Country:US
Mailing Address - Phone:607-271-2050
Mailing Address - Fax:
Practice Address - Street 1:2977 WESTINGHOUSE RD
Practice Address - Street 2:SUITE 3
Practice Address - City:HORSEHEADS
Practice Address - State:NY
Practice Address - Zip Code:14845-8120
Practice Address - Country:US
Practice Address - Phone:607-873-1832
Practice Address - Fax:607-873-1833
Is Sole Proprietor?:No
Enumeration Date:2012-03-19
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015194-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04403196Medicaid