Provider Demographics
NPI:1174119598
Name:LUO, KERY
Entity type:Individual
Prefix:
First Name:KERY
Middle Name:
Last Name:LUO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 E NORTH ST
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336-4932
Mailing Address - Country:US
Mailing Address - Phone:209-823-3111
Mailing Address - Fax:
Practice Address - Street 1:1205 E NORTH ST
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336-4932
Practice Address - Country:US
Practice Address - Phone:209-823-3111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-19
Last Update Date:2022-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
CAPA59226363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant