Provider Demographics
NPI:1992992861
Name:SEDDELMEYER, LUKE W (PA)
Entity type:Individual
Prefix:
First Name:LUKE
Middle Name:W
Last Name:SEDDELMEYER
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 1:6451 BRENTWOOD STAIR RD STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76112-3200
Mailing Address - Country:US
Mailing Address - Phone:817-496-9700
Mailing Address - Fax:
Practice Address - Street 1:8200 WALNUT HILL LN
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4426
Practice Address - Country:US
Practice Address - Phone:214-345-6789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-25
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA06208363A00000X
MI5601005095363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX283587802Medicaid
TXP01042097OtherMEDICARE RAILROAD
TX283587801Medicaid
TXTXB124117Medicare PIN
MIC37626072Medicare PIN
TXP01042097OtherMEDICARE RAILROAD
TXTXB136639Medicare PIN
TXTXB124119Medicare PIN