Provider Demographics
NPI:1194095943
Name:LUCK, RUTH
Entity type:Individual
Prefix:MS
First Name:RUTH
Middle Name:
Last Name:LUCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RUTH
Other - Middle Name:
Other - Last Name:JENSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 1625
Mailing Address - Street 2:
Mailing Address - City:PAGE
Mailing Address - State:AZ
Mailing Address - Zip Code:86040-1625
Mailing Address - Country:US
Mailing Address - Phone:928-645-9675
Mailing Address - Fax:
Practice Address - Street 1:3272 E RIO VIRGIN RD
Practice Address - Street 2:
Practice Address - City:LITTLEFIELD
Practice Address - State:AZ
Practice Address - Zip Code:86432-3200
Practice Address - Country:US
Practice Address - Phone:928-347-5971
Practice Address - Fax:928-347-5793
Is Sole Proprietor?:No
Enumeration Date:2012-01-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363A00000X
AZ5639363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ894489Medicaid