Provider Demographics
NPI:1285966002
Name:LUTZ, JOHANNAH (PA-C)
Entity type:Individual
Prefix:
First Name:JOHANNAH
Middle Name:
Last Name:LUTZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19075 NW TANASBOURNE DR
Mailing Address - Street 2:STE 200
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97124-5860
Mailing Address - Country:US
Mailing Address - Phone:503-684-8252
Mailing Address - Fax:
Practice Address - Street 1:202 NW 13TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-2953
Practice Address - Country:US
Practice Address - Phone:503-684-8252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-03
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA159810363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORPA159810OtherOREGON MEDICAL BOARD