Provider Demographics
NPI:1063711828
Name:LUTTRELL, SCOTT RANDALL
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:RANDALL
Last Name:LUTTRELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2106 SPUR CANYON CT
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77469-7251
Mailing Address - Country:US
Mailing Address - Phone:786-693-0596
Mailing Address - Fax:
Practice Address - Street 1:2106 SPUR CANYON CT
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77469-7251
Practice Address - Country:US
Practice Address - Phone:786-693-0596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-19
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS876819163W00000X
TX656163367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse