Provider Demographics
NPI:1366469033
Name:LUECK, MICHELLE A (PA-C)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:A
Last Name:LUECK
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 1:201 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:ENDERLIN
Mailing Address - State:ND
Mailing Address - Zip Code:58027-1325
Mailing Address - Country:US
Mailing Address - Phone:701-437-3320
Mailing Address - Fax:701-437-3323
Practice Address - Street 1:201 4TH AVE
Practice Address - Street 2:
Practice Address - City:ENDERLIN
Practice Address - State:ND
Practice Address - Zip Code:58027-1325
Practice Address - Country:US
Practice Address - Phone:701-437-3320
Practice Address - Fax:701-437-3323
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2022-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPAC0150363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN012890200Medicaid
ND71086Medicaid
ND71086Medicaid
NDN22033Medicare PIN