Provider Demographics
NPI:1407964984
Name:KUNZE, LUCAS A (MPT)
Entity Type:Individual
Prefix:
First Name:LUCAS
Middle Name:A
Last Name:KUNZE
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N5241 US HWY 45
Mailing Address - Street 2:
Mailing Address - City:WATERSMEET
Mailing Address - State:MI
Mailing Address - Zip Code:49969-0009
Mailing Address - Country:US
Mailing Address - Phone:063-584-5889
Mailing Address - Fax:
Practice Address - Street 1:N5241 US HWY
Practice Address - Street 2:
Practice Address - City:WATERSMEET
Practice Address - State:MI
Practice Address - Zip Code:49969-4996
Practice Address - Country:US
Practice Address - Phone:906-358-4588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-26
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501018634225100000X
WI10301024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP00214353OtherRAILROAD MEDICARE NUMBER
ILK22207OtherMEDICARE NUMBER
WI0604410001OtherDMERC
WI40447500Medicaid
WIP00214353OtherRAILROAD MEDICARE NUMBER
WI40447500Medicaid