Provider Demographics
NPI:1609936772
Name:LUTGEN, JEANINE (PA-C)
Entity Type:Individual
Prefix:
First Name:JEANINE
Middle Name:
Last Name:LUTGEN
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:PO BOX 436
Mailing Address - Street 2:
Mailing Address - City:LAVEEN
Mailing Address - State:AZ
Mailing Address - Zip Code:85339-0436
Mailing Address - Country:US
Mailing Address - Phone:602-795-3371
Mailing Address - Fax:
Practice Address - Street 1:4521 W HOPI TRL
Practice Address - Street 2:
Practice Address - City:LAVEEN
Practice Address - State:AZ
Practice Address - Zip Code:85339-2068
Practice Address - Country:US
Practice Address - Phone:602-795-3371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3608363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ284600Medicaid
AZS52937Medicare UPIN