Provider Demographics
NPI:1720118912
Name:HERDINA, LUKE A (PA-C)
Entity type:Individual
Prefix:
First Name:LUKE
Middle Name:A
Last Name:HERDINA
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:P.O. BOX 539
Mailing Address - Street 2:16830 198TH AVE NW BIG LAKE CLINIC
Mailing Address - City:BIG LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55309
Mailing Address - Country:US
Mailing Address - Phone:763-263-7300
Mailing Address - Fax:
Practice Address - Street 1:16830 198TH AVE NW
Practice Address - Street 2:BIG LAKE CLINIC
Practice Address - City:BIG LAKE
Practice Address - State:MN
Practice Address - Zip Code:55309
Practice Address - Country:US
Practice Address - Phone:763-263-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2009-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0630363AM0700X
MN1259363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical