Provider Demographics
NPI:1134626765
Name:LUTZ, NATHAN (MS, AT, ATC)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:LUTZ
Suffix:
Gender:M
Credentials:MS, AT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4254 TURTLE BEND DR SW APT 5
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-2516
Mailing Address - Country:US
Mailing Address - Phone:616-648-7505
Mailing Address - Fax:
Practice Address - Street 1:2770 KNAPP ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-4422
Practice Address - Country:US
Practice Address - Phone:616-648-7505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-10
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010011002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer