Healthcare Provider Details

I. General information

NPI: 1093689382
Provider Name (Legal Business Name): LUCAS JORDAN SKOLKIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2025
Last Update Date: 10/01/2025
Certification Date: 09/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 FULTON AVENUE
HEMPSTEAD NY
11550
US

IV. Provider business mailing address

270 SHORE RD APT 2
LONG BEACH NY
11561-4219
US

V. Phone/Fax

Practice location:
  • Phone: 516-463-6600
  • Fax:
Mailing address:
  • Phone: 973-796-6864
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: