Provider Demographics
NPI:1932292570
Name:DELUCA, MYRA M (PA-C)
Entity Type:Individual
Prefix:
First Name:MYRA
Middle Name:M
Last Name:DELUCA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MYRA
Other - Middle Name:
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1401 HARRODSBURG RD
Mailing Address - Street 2:SUITE C-235
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-3751
Mailing Address - Country:US
Mailing Address - Phone:859-276-1578
Mailing Address - Fax:859-276-2392
Practice Address - Street 1:1401 HARRODSBURG RD
Practice Address - Street 2:SUITE C-235
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-3751
Practice Address - Country:US
Practice Address - Phone:859-276-1578
Practice Address - Fax:859-276-2392
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2009-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA348363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACB5773OtherRR MEDICARE GRP
GAP00356806OtherRR MEDICARE PIN
KY4000501OtherMEDICARE LAB GRP
GACB5773OtherRR MEDICARE GRP
KY0016962Medicare PIN
S78373Medicare UPIN