Provider Demographics
NPI:1902447154
Name:GOLUCKE, REAGAN
Entity Type:Individual
Prefix:
First Name:REAGAN
Middle Name:
Last Name:GOLUCKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11413 LAKE TANA DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936-3904
Mailing Address - Country:US
Mailing Address - Phone:915-525-0630
Mailing Address - Fax:
Practice Address - Street 1:11413 LAKE TANA DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-3904
Practice Address - Country:US
Practice Address - Phone:915-525-0630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-30
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program