Provider Demographics
NPI:1689380941
Name:MUTZ, BRIANNA ISABELLE (PA)
Entity type:Individual
Prefix:
First Name:BRIANNA
Middle Name:ISABELLE
Last Name:MUTZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:BRIANNA
Other - Middle Name:ISABELLE
Other - Last Name:GRUBER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:2995 DREW ST
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33759-3012
Mailing Address - Country:US
Mailing Address - Phone:727-315-7496
Mailing Address - Fax:
Practice Address - Street 1:3301 W GANDY BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33611-2931
Practice Address - Country:US
Practice Address - Phone:813-925-1903
Practice Address - Fax:813-749-8370
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-30
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9116974363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9116974OtherFL ST LICENSE