Healthcare Provider Details

I. General information

NPI: 1376313668
Provider Name (Legal Business Name): AVIGAYIL RUTH LUCHANSKY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. AVIGAYIL RUTH BLOOM

II. Dates (important events)

Enumeration Date: 01/08/2024
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 WALKER AVE
PIKESVILLE MD
21208-4022
US

IV. Provider business mailing address

3501 CLARKS LANE APT C1
BALTIMORE MD
21215-2500
US

V. Phone/Fax

Practice location:
  • Phone: 410-415-3515
  • Fax:
Mailing address:
  • Phone: 973-883-5367
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0010662
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: