Provider Demographics
NPI:1487884672
Name:LUCZAK, AMY K (PA-C)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:K
Last Name:LUCZAK
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 1:6550 FANNIN ST
Mailing Address - Street 2:SUITE 1401
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2717
Mailing Address - Country:US
Mailing Address - Phone:713-441-5200
Mailing Address - Fax:
Practice Address - Street 1:6550 FANNIN ST
Practice Address - Street 2:SUITE 1401
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2717
Practice Address - Country:US
Practice Address - Phone:713-441-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-22
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05821363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX209315504Medicaid
TXP01152529OtherRR MEDICARE
TXP01337851OtherRR MEDICARE
TX209315505Medicaid
TX884N22OtherBCBS
TX1487884672OtherBLUE CROSS BLUE SHIELD
TX328342YMVQMedicare PIN
TXTXB164142Medicare PIN
TX209315505Medicaid