1750387387 NPI number — MRS. AMBER D LUTZ PA-C

Table of content: MRS. AMBER D LUTZ PA-C (NPI 1750387387)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750387387 NPI number — MRS. AMBER D LUTZ PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LUTZ
Provider First Name:
AMBER
Provider Middle Name:
D
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FETCHER
Provider Other First Name:
AMBER
Provider Other Middle Name:
D
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
P.A.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1750387387
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/14/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1202 W BUENA VISTA RD.
Provider Second Line Business Mailing Address:
SUITE # 100
Provider Business Mailing Address City Name:
EVANSVILLE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47710-5185
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-429-1520
Provider Business Mailing Address Fax Number:
812-429-1523

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1202 W BUENA VISTA RD.
Provider Second Line Business Practice Location Address:
SUITE #100
Provider Business Practice Location Address City Name:
EVANSVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47710-5185
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-429-1520
Provider Business Practice Location Address Fax Number:
812-429-1523
Provider Enumeration Date:
06/28/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  085002198 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 10000657A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 970010159 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com