Provider Demographics
NPI:1942589080
Name:LUETMER, SUSAN MICHELLE (PA-C)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MICHELLE
Last Name:LUETMER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:MICHELLE
Other - Last Name:DECKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3701 12TH ST N
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-2255
Mailing Address - Country:US
Mailing Address - Phone:320-253-7257
Mailing Address - Fax:320-251-2938
Practice Address - Street 1:3701 12TH ST N
Practice Address - Street 2:SUITE 100
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-2255
Practice Address - Country:US
Practice Address - Phone:320-253-7257
Practice Address - Fax:320-251-2938
Is Sole Proprietor?:No
Enumeration Date:2011-08-08
Last Update Date:2014-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV01570363AM0700X
MN11268363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical