Healthcare Provider Details

I. General information

NPI: 1922192954
Provider Name (Legal Business Name): LUKE MATTHEW REQUA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 11/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 S J ST
TACOMA WA
98405-4933
US

IV. Provider business mailing address

1717 S J ST
TACOMA WA
98405-4933
US

V. Phone/Fax

Practice location:
  • Phone: 253-426-6341
  • Fax: 253-426-6344
Mailing address:
  • Phone: 253-426-6341
  • Fax: 253-426-6344

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA10004390
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: