Healthcare Provider Details

I. General information

NPI: 1841821881
Provider Name (Legal Business Name): EREK JOURDAN LUCIO PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2020
Last Update Date: 01/20/2021
Certification Date: 01/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2310 HEMPSTEAD TPKE
EAST MEADOW NY
11554-2035
US

IV. Provider business mailing address

465 JEFFERSON PL
MINEOLA NY
11501-2215
US

V. Phone/Fax

Practice location:
  • Phone: 516-346-5090
  • Fax:
Mailing address:
  • Phone: 516-884-4351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number026219
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: