Healthcare Provider Details

I. General information

NPI: 1689499246
Provider Name (Legal Business Name): LUKE ADAM PENG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2024
Last Update Date: 12/17/2024
Certification Date: 12/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 W STATE ROAD 434
LONGWOOD FL
32750-5119
US

IV. Provider business mailing address

555 W STATE ROAD 434
LONGWOOD FL
32750-5119
US

V. Phone/Fax

Practice location:
  • Phone: 407-767-1200
  • Fax:
Mailing address:
  • Phone: 321-842-8505
  • Fax: 321-843-5550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number11036482
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAPRN11036482
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: