Provider Demographics
NPI:1710511688
Name:LUTZ, ANDREW
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:LUTZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:655 S WILLOW ST STE 128
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03103-5723
Mailing Address - Country:US
Mailing Address - Phone:800-995-2673
Mailing Address - Fax:
Practice Address - Street 1:655 S WILLOW ST STE 128
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03103-5723
Practice Address - Country:US
Practice Address - Phone:800-995-2673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-28
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN12817225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist