Provider Demographics
NPI:1952844136
Name:LUCA, STEPHANIE JOANNE (PA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:JOANNE
Last Name:LUCA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 UNION AVE
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-1704
Mailing Address - Country:US
Mailing Address - Phone:631-585-5858
Mailing Address - Fax:631-585-6362
Practice Address - Street 1:203 UNION AVE
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741-1704
Practice Address - Country:US
Practice Address - Phone:631-585-5858
Practice Address - Fax:631-585-6362
Is Sole Proprietor?:No
Enumeration Date:2016-11-21
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020384363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant