Organization
JDL-CTSPA
Active
Organization
JDL-CTSPA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. JEANINE DIANE LUTGEN PA-C (MANAGER)
(602) 795-3371
Entity
Organization
Contact information
Practice address
4521 W HOPI TRL, LAVEEN, AZ 85339-2068
(602) 795-3371
Mailing address
PO BOX 436, LAVEEN, AZ 85339-0436
(027) 953-3716
Taxonomy
Speciality
Code
Description
License number
State
363AS0400X
Surgical Physician Assistant
Primary
3608
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
Z123651
MEDICARE PTAN
AZ
Enumeration date
07/14/2008
Last updated
04/08/2019
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