Provider Demographics
NPI:1194130328
Name:LUU, BAOTRAM NGOC (PA-C, MPAS)
Entity type:Individual
Prefix:
First Name:BAOTRAM
Middle Name:NGOC
Last Name:LUU
Suffix:
Gender:F
Credentials:PA-C, MPAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:ONE MEDICAL CENTER BLVD
Mailing Address - Street 2:SUITE 404
Mailing Address - City:UPLAND
Mailing Address - State:PA
Mailing Address - Zip Code:19013
Mailing Address - Country:US
Mailing Address - Phone:610-619-8590
Mailing Address - Fax:610-619-8591
Practice Address - Street 1:ONE MEDICAL CENTER BLVD
Practice Address - Street 2:SUITE 404
Practice Address - City:UPLAND
Practice Address - State:PA
Practice Address - Zip Code:19013
Practice Address - Country:US
Practice Address - Phone:610-619-8590
Practice Address - Fax:610-619-8591
Is Sole Proprietor?:No
Enumeration Date:2014-06-26
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA051657363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant