Healthcare Provider Details

I. General information

NPI: 1184121279
Provider Name (Legal Business Name): LUKE ENNIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2018
Last Update Date: 05/04/2023
Certification Date: 05/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 RIVERSIDE CIR
ROANOKE VA
24016-4955
US

IV. Provider business mailing address

213 S JEFFERSON ST STE 1006
ROANOKE VA
24011-1713
US

V. Phone/Fax

Practice location:
  • Phone: 540-224-5170
  • Fax: 540-983-8229
Mailing address:
  • Phone: 540-224-5352
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number2021-01409
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: