Provider Demographics
NPI:1306313531
Name:LUECK, KSENIYA ALEKSEYEVNA (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KSENIYA
Middle Name:ALEKSEYEVNA
Last Name:LUECK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KSENIYA
Other - Middle Name:ALEKSEYEVNA
Other - Last Name:MYALIK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:7261 MERCY RD
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68124-2311
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1625 N 205TH ST
Practice Address - Street 2:
Practice Address - City:ELKHORN
Practice Address - State:NE
Practice Address - Zip Code:68022-4885
Practice Address - Country:US
Practice Address - Phone:402-758-5452
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-25
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA127741363A00000X
390200000X
NE2976363A00000X
OK4444363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program