Provider Demographics
NPI:1265437347
Name:LUGO, NICHOLE E (PA)
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:E
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 1:11040 VISTA DEL SOL DR STE C
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79935-4314
Mailing Address - Country:US
Mailing Address - Phone:915-591-7704
Mailing Address - Fax:915-591-7734
Practice Address - Street 1:11040 VISTA DEL SOL DR STE C
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79935-4314
Practice Address - Country:US
Practice Address - Phone:915-591-7704
Practice Address - Fax:915-591-7734
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03694363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX182328802Medicaid
NM68325886Medicaid
TX182328801Medicaid
TX182328802Medicaid
NM68325886Medicaid
TX8K7228Medicare PIN
TX8B1208Medicare ID - Type Unspecified