Provider Demographics
NPI:1568550804
Name:LUTZ, KYLE A (PA)
Entity Type:Individual
Prefix:MR
First Name:KYLE
Middle Name:A
Last Name:LUTZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:520 MARY ST
Mailing Address - Street 2:STE 520
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47710-1682
Mailing Address - Country:US
Mailing Address - Phone:812-424-8231
Mailing Address - Fax:812-435-8794
Practice Address - Street 1:520 MARY ST STE 520
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47710-1682
Practice Address - Country:US
Practice Address - Phone:812-424-8231
Practice Address - Fax:812-435-8794
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN10000720A363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000335308OtherANTHEM BCBS
IN100000720OtherINDIANA STATE LICENSE
IN300007791Medicaid
KY9500485900Medicaid
KY9500485900Medicaid