Healthcare Provider Details

I. General information

NPI: 1841810645
Provider Name (Legal Business Name): BRENDA J LUGO PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2020
Last Update Date: 02/05/2024
Certification Date: 02/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 E UNIVERSITY AVE
DES MOINES IA
50316-2304
US

IV. Provider business mailing address

810 PIERCE ST
IOWA FALLS IA
50126-1417
US

V. Phone/Fax

Practice location:
  • Phone: 515-265-4211
  • Fax:
Mailing address:
  • Phone: 515-480-3845
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number105583
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number105583
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: