Healthcare Provider Details

I. General information

NPI: 1972857605
Provider Name (Legal Business Name): TERESA LUTHER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2012
Last Update Date: 05/09/2025
Certification Date: 05/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 W CYPRESS CREEK RD STE C100
FORT LAUDERDALE FL
33309-1741
US

IV. Provider business mailing address

5220 NE 20TH AVE
FORT LAUDERDALE FL
33308-3121
US

V. Phone/Fax

Practice location:
  • Phone: 954-974-3111
  • Fax:
Mailing address:
  • Phone: 954-873-2926
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9106899
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9106899
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: