Provider Demographics
NPI:1982253084
Name:LUO, MICHELLE YUNRUI (PA-C)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:YUNRUI
Last Name:LUO
Suffix:
Gender:F
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 1:13668 ROOSEVELT AVE
Mailing Address - Street 2:STE 4A-B
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-5510
Mailing Address - Country:US
Mailing Address - Phone:718-539-3648
Mailing Address - Fax:
Practice Address - Street 1:13668 ROOSEVELT AVE # 4A-B
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-5510
Practice Address - Country:US
Practice Address - Phone:718-539-3648
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-10
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023984363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant