Provider Demographics
NPI:1528149788
Name:KUTZ, JOEL (PA-C)
Entity type:Individual
Prefix:
First Name:JOEL
Middle Name:
Last Name:KUTZ
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 1:40686 SAINT LOUIS DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-7129
Mailing Address - Country:US
Mailing Address - Phone:586-822-4796
Mailing Address - Fax:
Practice Address - Street 1:3100 CROSS CREEK PKWY
Practice Address - Street 2:STE. 200
Practice Address - City:AUBURN HILLS
Practice Address - State:MI
Practice Address - Zip Code:48326-2776
Practice Address - Country:US
Practice Address - Phone:248-377-8000
Practice Address - Fax:248-377-2929
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004522363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Not Answered363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601004522OtherSTATE LICENSE
MIOP18210Medicare PIN