Provider Demographics
NPI:1205022605
Name:LUTZ, WANDA M
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:M
Last Name:LUTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 E FIRST ST
Mailing Address - Street 2:
Mailing Address - City:TRINIDAD
Mailing Address - State:CO
Mailing Address - Zip Code:81082-3001
Mailing Address - Country:US
Mailing Address - Phone:719-846-4990
Mailing Address - Fax:719-846-3505
Practice Address - Street 1:165 E FIRST ST
Practice Address - Street 2:
Practice Address - City:TRINIDAD
Practice Address - State:CO
Practice Address - Zip Code:81082-3001
Practice Address - Country:US
Practice Address - Phone:719-846-4990
Practice Address - Fax:719-846-3505
Is Sole Proprietor?:No
Enumeration Date:2007-09-19
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1C17893Medicare PIN