Healthcare Provider Details

I. General information

NPI: 1154362564
Provider Name (Legal Business Name): WAYNE C. LUCKE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 NE 139TH ST
VANCOUVER WA
98686-2742
US

IV. Provider business mailing address

6312 SW CAPITOL HWY #502
PORTLAND OR
97239-1938
US

V. Phone/Fax

Practice location:
  • Phone: 360-487-1400
  • Fax:
Mailing address:
  • Phone: 503-464-9034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD00018493
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: