Provider Demographics
NPI:1093922668
Name:LUTZ, BEN H (PA-C)
Entity Type:Individual
Prefix:MR
First Name:BEN
Middle Name:H
Last Name:LUTZ
Suffix:
Gender:M
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 1:811 WEDGEWOOD CT
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92376-8714
Mailing Address - Country:US
Mailing Address - Phone:909-875-8451
Mailing Address - Fax:
Practice Address - Street 1:245 TERRACINA BLVD STE 106C
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-4899
Practice Address - Country:US
Practice Address - Phone:909-748-6569
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA14783363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant