Basic Information
| Provider Information | |||||||||
| NPI: | 1285966002 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LUTZ | ||||||||
| FirstName: | JOHANNAH | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19075 NW TANASBOURNE DR | ||||||||
| Address2: | STE 200 | ||||||||
| City: | HILLSBORO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971245860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036848252 | ||||||||
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| Practice Location | |||||||||
| Address1: | 202 NW 13TH AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972092953 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036848252 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2010 | ||||||||
| LastUpdateDate: | 10/19/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA159810 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | PA159810 | 01 | OR | OREGON MEDICAL BOARD | OTHER |