Provider Demographics
NPI:1881148005
Name:LUECKE, KALI (PA-C)
Entity type:Individual
Prefix:
First Name:KALI
Middle Name:
Last Name:LUECKE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KALI
Other - Middle Name:
Other - Last Name:SHEPHARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:301 NP AVE N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-4835
Mailing Address - Country:US
Mailing Address - Phone:701-271-3344
Mailing Address - Fax:701-271-1480
Practice Address - Street 1:301 NP AVE N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-4835
Practice Address - Country:US
Practice Address - Phone:701-271-3344
Practice Address - Fax:701-271-1480
Is Sole Proprietor?:No
Enumeration Date:2016-08-04
Last Update Date:2019-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.005909363AM0700X
NDPAC0748363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical