Provider Demographics
NPI:1366900607
Name:LUKE, JARED WILSON (PA-C)
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:WILSON
Last Name:LUKE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:501 OFFICE CENTER DR STE 195
Mailing Address - Street 2:
Mailing Address - City:FORT WASHINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:19034-3268
Mailing Address - Country:US
Mailing Address - Phone:215-836-7900
Mailing Address - Fax:215-836-7923
Practice Address - Street 1:501 OFFICE CENTER DR STE 195
Practice Address - Street 2:
Practice Address - City:FORT WASHINGTON
Practice Address - State:PA
Practice Address - Zip Code:19034-3268
Practice Address - Country:US
Practice Address - Phone:215-836-7900
Practice Address - Fax:215-836-7923
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-06
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA060528363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant