Basic Information
| Provider Information | |||||||||
| NPI: | 1558325571 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LUTZ | ||||||||
| FirstName: | PATRICIA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2915 3RD AVE STE 3500 | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257021401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046918900 | ||||||||
| FaxNumber: | 3045256238 | ||||||||
| Practice Location | |||||||||
| Address1: | 2915 3RD AVE | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257021401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046918900 | ||||||||
| FaxNumber: | 3045256238 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2006 | ||||||||
| LastUpdateDate: | 12/28/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 18650 | WV | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 64941750 | 05 | KY | MEDICAID | 2021485 | 05 | OH | MEDICAID | 0110857000 | 05 | WV | MEDICAID |