Provider Demographics
NPI:1801888094
Name:LUCKE, REBECCA L (CRNA)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:L
Last Name:LUCKE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5135 N HARBORSIDE CT
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67204-2370
Mailing Address - Country:US
Mailing Address - Phone:316-258-1948
Mailing Address - Fax:
Practice Address - Street 1:5135 N HARBORSIDE CT
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67204-2370
Practice Address - Country:US
Practice Address - Phone:316-258-1948
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2012-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS54337367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100252910EMedicaid
KS100252910AMedicaid
KS043045OtherBCBS
430023314OtherRR MEDICARE GROUP CK2307
KS144663Medicare ID - Type Unspecified
R31633Medicare UPIN
KS100252910AMedicaid