Provider Demographics
NPI:1518114891
Name:KUTRIEB, LUKE H (PA)
Entity Type:Individual
Prefix:
First Name:LUKE
Middle Name:H
Last Name:KUTRIEB
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 1:321 E WARWICK DR
Mailing Address - Street 2:
Mailing Address - City:ALMA
Mailing Address - State:MI
Mailing Address - Zip Code:48801-1084
Mailing Address - Country:US
Mailing Address - Phone:989-466-3332
Mailing Address - Fax:989-466-6805
Practice Address - Street 1:321 E WARWICK DR
Practice Address - Street 2:
Practice Address - City:ALMA
Practice Address - State:MI
Practice Address - Zip Code:48801-1084
Practice Address - Country:US
Practice Address - Phone:989-466-3332
Practice Address - Fax:989-466-6805
Is Sole Proprietor?:No
Enumeration Date:2008-08-19
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005326363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1152915200OtherBCBSM
MIM02890001Medicare PIN