Basic Information
| Provider Information | |||||||||
| NPI: | 1942938527 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SUN | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | LUGTU | ||||||||
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| Credential: | MSN,BSN,CPE,FNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 311 BOYD BLVD | ||||||||
| Address2: | |||||||||
| City: | LA PORTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463503965 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193262664 | ||||||||
| FaxNumber: | 2193262653 | ||||||||
| Practice Location | |||||||||
| Address1: | 311 BOYD BLVD | ||||||||
| Address2: | |||||||||
| City: | LA PORTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463503965 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193262664 | ||||||||
| FaxNumber: | 2193262653 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2022 | ||||||||
| LastUpdateDate: | 08/15/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 71012833A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.