Provider Demographics
NPI:1427886134
Name:LUGO, MIGUEL EDUARDO (PA)
Entity type:Individual
Prefix:
First Name:MIGUEL
Middle Name:EDUARDO
Last Name:LUGO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 WYTHE CT
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-4637
Mailing Address - Country:US
Mailing Address - Phone:787-518-0361
Mailing Address - Fax:
Practice Address - Street 1:2925 WYTHE CT
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-4637
Practice Address - Country:US
Practice Address - Phone:787-518-0361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-24
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
AZ10482363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant