Provider Demographics
NPI:1447337688
Name:LUTHER, MICHAEL WILLIAM (PA-C)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:WILLIAM
Last Name:LUTHER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:44199 DEQUINDRE RD STE G-10
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48085-1128
Practice Address - Country:US
Practice Address - Phone:248-964-6111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA19796363A00000X
MI5601003566363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW18762OtherGROUP MEDICARE
CA1902846306OtherGROUP NPI
CAGR0100430OtherGROUP MEDICAL
CAW18762OtherGROUP MEDICARE