Healthcare Provider Details

I. General information

NPI: 1932084837
Provider Name (Legal Business Name): LUMEN SKIN HEALTH PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2025
Last Update Date: 11/01/2025
Certification Date: 11/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 NEWPORT CENTER DR STE M101
NEWPORT BEACH CA
92660-7516
US

IV. Provider business mailing address

500 S ANAHEIM HILLS RD STE 242
ANAHEIM CA
92807-4760
US

V. Phone/Fax

Practice location:
  • Phone: 949-414-8426
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: TRACY WIEGAND
Title or Position: CFO & SECRETARY
Credential:
Phone: 949-414-8426