Provider Demographics
NPI:1841810645
Name:LUGO, BRENDA J (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:J
Last Name:LUGO
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 PIERCE ST
Mailing Address - Street 2:
Mailing Address - City:IOWA FALLS
Mailing Address - State:IA
Mailing Address - Zip Code:50126-1417
Mailing Address - Country:US
Mailing Address - Phone:515-480-3845
Mailing Address - Fax:
Practice Address - Street 1:840 E UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50316-2304
Practice Address - Country:US
Practice Address - Phone:515-265-4211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-21
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA105583363AM0700X, 363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program