Healthcare Provider Details

I. General information

NPI: 1417956848
Provider Name (Legal Business Name): ELIAS LU DTCM, AP, APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2005
Last Update Date: 11/13/2025
Certification Date: 11/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5920 PAN AMERICAN BLVD STE 208B
NORTH PORT FL
34287-3412
US

IV. Provider business mailing address

5753 HIGHWAY 85 N STE 6387
CRESTVIEW FL
32536-9365
US

V. Phone/Fax

Practice location:
  • Phone: 888-354-2758
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11011629
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAP4251
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: