Healthcare Provider Details

I. General information

NPI: 1821314378
Provider Name (Legal Business Name): LUKE JOSEPH BOOTZ CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2010
Last Update Date: 05/19/2025
Certification Date: 05/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 ATKINSON DR
LUDINGTON MI
49431-1906
US

IV. Provider business mailing address

100 MICHIGAN ST NE # MC845
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 231-845-2539
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704279085
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: