Provider Demographics
NPI:1245248426
Name:LUGO, KELLI (PA)
Entity type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:
Last Name:LUGO
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 1:7710 S US HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-2320
Mailing Address - Country:US
Mailing Address - Phone:772-446-7209
Mailing Address - Fax:772-200-2131
Practice Address - Street 1:7710 S US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-2320
Practice Address - Country:US
Practice Address - Phone:772-446-7209
Practice Address - Fax:772-200-2131
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9107919363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOPA174151OtherMEDICARE IDENTIFICATION NUMBER