Provider Demographics
NPI:1831353382
Name:JDL-CTSPA
Entity type:Organization
Organization Name:JDL-CTSPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JEANINE
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:LUTGEN
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:602-795-3371
Mailing Address - Street 1:PO BOX 436
Mailing Address - Street 2:
Mailing Address - City:LAVEEN
Mailing Address - State:AZ
Mailing Address - Zip Code:85339-0436
Mailing Address - Country:US
Mailing Address - Phone:027-953-3716
Mailing Address - Fax:
Practice Address - Street 1:4521 W HOPI TRL
Practice Address - Street 2:
Practice Address - City:LAVEEN
Practice Address - State:AZ
Practice Address - Zip Code:85339-2068
Practice Address - Country:US
Practice Address - Phone:602-795-3371
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-14
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3608363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ123651OtherMEDICARE PTAN