Provider Demographics
NPI:1467506774
Name:LUTZ, MICHAEL DENNIS (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DENNIS
Last Name:LUTZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1099 COUNTRY LN
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:NC
Mailing Address - Zip Code:28658-9312
Mailing Address - Country:US
Mailing Address - Phone:828-466-2230
Mailing Address - Fax:
Practice Address - Street 1:1940 BRIARWOOD DR
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28602-5497
Practice Address - Country:US
Practice Address - Phone:828-294-1116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC100642363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC100642OtherSTATE LICENSE NO