Provider Demographics
NPI:1831844968
Name:DUTKO, LAURIE (PA-C)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:
Last Name:DUTKO
Suffix:
Gender:F
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:PO BOX 24607
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68124-0607
Mailing Address - Country:US
Mailing Address - Phone:402-955-5400
Mailing Address - Fax:402-955-3674
Practice Address - Street 1:8200 DODGE ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-4113
Practice Address - Country:US
Practice Address - Phone:402-955-5372
Practice Address - Fax:402-955-5380
Is Sole Proprietor?:No
Enumeration Date:2022-02-17
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60381363AM0700X
WAPA61171019363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical