Provider Demographics
NPI:1538172259
Name:ALLEN, LUKE G
Entity type:Individual
Prefix:
First Name:LUKE
Middle Name:G
Last Name:ALLEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 DRIFTWOOD LANE
Mailing Address - Street 2:
Mailing Address - City:EAST MORICHES
Mailing Address - State:NY
Mailing Address - Zip Code:11940
Mailing Address - Country:US
Mailing Address - Phone:631-874-4567
Mailing Address - Fax:
Practice Address - Street 1:1300 ROANOKE AVE
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901
Practice Address - Country:US
Practice Address - Phone:631-548-6440
Practice Address - Fax:631-548-6446
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007280-1363A00000X
363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P09461Medicare UPIN