Provider Demographics
NPI:1750387387
Name:LUTZ, AMBER D (PA-C)
Entity type:Individual
Prefix:MRS
First Name:AMBER
Middle Name:D
Last Name:LUTZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AMBER
Other - Middle Name:D
Other - Last Name:FETCHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1202 W BUENA VISTA RD.
Mailing Address - Street 2:SUITE # 100
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47710-5185
Mailing Address - Country:US
Mailing Address - Phone:812-429-1520
Mailing Address - Fax:812-429-1523
Practice Address - Street 1:1202 W BUENA VISTA RD.
Practice Address - Street 2:SUITE #100
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47710-5185
Practice Address - Country:US
Practice Address - Phone:812-429-1520
Practice Address - Fax:812-429-1523
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085002198363A00000X
IN10000657A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH970010159OtherMEDICARE RAILROAD
OHLUPA75071Medicare PIN
ILQ10996Medicare UPIN
OH970010159OtherMEDICARE RAILROAD
OHS 16709Medicare UPIN
IL208634Medicare ID - Type Unspecified
INC25864Medicare UPIN