Provider Demographics
NPI:1669131272
Name:LUKOMSKY, DAVID GRANT (PA-C)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:GRANT
Last Name:LUKOMSKY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:931 W GREAT BASIN DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-4574
Mailing Address - Country:US
Mailing Address - Phone:208-724-9391
Mailing Address - Fax:
Practice Address - Street 1:721 RIVER DR STE C
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:CA
Practice Address - Zip Code:95437
Practice Address - Country:US
Practice Address - Phone:707-961-4995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-10
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA60459363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant