Provider Demographics
NPI:1841913456
Name:LUKE, MIRA RHAE (PA-C)
Entity type:Individual
Prefix:
First Name:MIRA
Middle Name:RHAE
Last Name:LUKE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MIRA
Other - Middle Name:RHAE
Other - Last Name:VONDERHEIDE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:18444 N 25TH AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85023-1266
Mailing Address - Country:US
Mailing Address - Phone:866-974-2673
Mailing Address - Fax:866-939-2673
Practice Address - Street 1:14520 W GRANITE VALLEY DR STE 210
Practice Address - Street 2:
Practice Address - City:SUN CITY WEST
Practice Address - State:AZ
Practice Address - Zip Code:85375-5855
Practice Address - Country:US
Practice Address - Phone:888-517-0958
Practice Address - Fax:866-939-2673
Is Sole Proprietor?:No
Enumeration Date:2022-09-20
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9270363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant