Provider Demographics
NPI:1417465550
Name:LUTZ, MATTHEW ANTHONY (PA-C)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:ANTHONY
Last Name:LUTZ
Suffix:
Gender:M
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 1:556 TEABERRY HILLS RD
Mailing Address - Street 2:
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28607-7075
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:965 STATE FARM RD
Practice Address - Street 2:
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607-4948
Practice Address - Country:US
Practice Address - Phone:828-264-2340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-10
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-07793363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant