Provider Demographics
NPI:1831137272
Name:LUTRICK, THOMAS MARK (PA-C)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:MARK
Last Name:LUTRICK
Suffix:
Gender:M
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 1255
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-1255
Mailing Address - Country:US
Mailing Address - Phone:214-227-2457
Mailing Address - Fax:
Practice Address - Street 1:4701 MANNING DR
Practice Address - Street 2:
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-4220
Practice Address - Country:US
Practice Address - Phone:214-227-2457
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-04
Last Update Date:2013-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03123363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical