Healthcare Provider Details

I. General information

NPI: 1922127695
Provider Name (Legal Business Name): MARI W. LUTZ P.T.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

687 LEE RD SUITE 208
ROCHESTER NY
14606-4257
US

IV. Provider business mailing address

687 LEE RD SUITE 208
ROCHESTER NY
14606-4257
US

V. Phone/Fax

Practice location:
  • Phone: 585-458-7910
  • Fax: 585-458-7507
Mailing address:
  • Phone: 585-458-7910
  • Fax: 585-458-7507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number005243
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: