Provider Demographics
NPI:1205816162
Name:LUETMER, STACEY LYNN (MD)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:LYNN
Last Name:LUETMER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23896 N LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:56334-9372
Mailing Address - Country:US
Mailing Address - Phone:320-491-1691
Mailing Address - Fax:800-878-9591
Practice Address - Street 1:23896 N LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:GLENWOOD
Practice Address - State:MN
Practice Address - Zip Code:56334-9372
Practice Address - Country:US
Practice Address - Phone:320-491-1691
Practice Address - Fax:800-878-9591
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-18
Last Update Date:2022-12-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN43321207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNP00305932OtherRR MEDICARE
MN398898800Medicaid
MN6697670002Medicare NSC
MN080022608Medicare PIN
H29067Medicare UPIN