Provider Demographics
NPI:1427377027
Name:LUCKENBILL, WAYNE P (PA-C)
Entity type:Individual
Prefix:MR
First Name:WAYNE
Middle Name:P
Last Name:LUCKENBILL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2494 BERNVILLE RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:READING
Mailing Address - State:PA
Mailing Address - Zip Code:19605-9469
Mailing Address - Country:US
Mailing Address - Phone:610-378-2996
Mailing Address - Fax:610-208-8812
Practice Address - Street 1:2500 BERNVILLE RD
Practice Address - Street 2:
Practice Address - City:READING
Practice Address - State:PA
Practice Address - Zip Code:19605-9453
Practice Address - Country:US
Practice Address - Phone:610-378-2996
Practice Address - Fax:610-208-8812
Is Sole Proprietor?:No
Enumeration Date:2010-05-21
Last Update Date:2016-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA002527363AS0400X
PAMA002432L363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAOA002527OtherLICENSE