Provider Demographics
NPI:1851531800
Name:LUTTRELL, MICHAEL S (NP, PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:S
Last Name:LUTTRELL
Suffix:
Gender:M
Credentials:NP, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 SILVER PINE CT
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-9266
Mailing Address - Country:US
Mailing Address - Phone:919-593-6086
Mailing Address - Fax:
Practice Address - Street 1:101 PROFESSIONAL PARK STE A
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:NC
Practice Address - Zip Code:27565-2580
Practice Address - Country:US
Practice Address - Phone:919-693-3972
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-04
Last Update Date:2009-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC201861363LF0000X
WI122695363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI500002725OtherMEDICARE RAILROAD
WI43845100Medicaid
WI000533035Medicare PIN
WI43845100Medicaid