Provider Demographics
NPI:1689325797
Name:LUTZ, AUSTIN MITCHEL (PA)
Entity Type:Individual
Prefix:
First Name:AUSTIN
Middle Name:MITCHEL
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 1:3671 W E AVE
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-6329
Mailing Address - Country:US
Mailing Address - Phone:269-598-8540
Mailing Address - Fax:
Practice Address - Street 1:1174 W MICHIGAN AVE STE B
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MI
Practice Address - Zip Code:49068-1625
Practice Address - Country:US
Practice Address - Phone:269-789-4390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-11
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical