Provider Demographics
NPI:1235141748
Name:LUTZ, MARK (PA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:LUTZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:5330 E STOP 11 RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-6345
Practice Address - Country:US
Practice Address - Phone:317-893-1900
Practice Address - Fax:317-893-1901
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN10000862A363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN117700EEEMedicare PIN
INQ73273Medicare UPIN