Provider Demographics
NPI:1518930338
Name:LAUTENBACH, JULIE A (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:A
Last Name:LAUTENBACH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:PELLA
Mailing Address - State:IA
Mailing Address - Zip Code:50219-1189
Mailing Address - Country:US
Mailing Address - Phone:641-628-3832
Mailing Address - Fax:641-621-2335
Practice Address - Street 1:405 MONROE ST
Practice Address - Street 2:
Practice Address - City:PELLA
Practice Address - State:IA
Practice Address - Zip Code:50219-1189
Practice Address - Country:US
Practice Address - Phone:641-628-3832
Practice Address - Fax:641-621-2335
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2014-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001511363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA71188OtherWELLMARK
IAI21738Medicare PIN
IA71188OtherWELLMARK