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General NPI Number Information
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NPI Number | 1932084837
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Entity Type | Organization
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Legal Business Name | LUMEN SKIN HEALTH PC
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Dates
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Enumeration Date | 08/08/2025
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Last Update Date | 11/01/2025
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Provider Practice Location Address
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Address Line | 250 NEWPORT CENTER DR STE M101
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City | NEWPORT BEACH
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State | CA
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Zip | 92660-7516
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Country | US
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Telephone | 949-414-8426
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Fax |
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Provider Business Mailing Address
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Address Line | 500 S ANAHEIM HILLS RD STE 242
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City | ANAHEIM
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State | CA
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Zip | 92807-4760
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CFO & SECRETARY
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Name | TRACY WIEGAND
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Credential |
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Telephone | 949-414-8426
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 208200000X
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Taxonomy Name | Plastic Surgery Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number |
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License Number State |
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