Provider Demographics
NPI:1689944779
Name:MIETZ, MICHAEL KEITH (PA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:KEITH
Last Name:MIETZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 BEVINS COURT
Mailing Address - Street 2:
Mailing Address - City:LAKEPORT
Mailing Address - State:CA
Mailing Address - Zip Code:95453-9754
Mailing Address - Country:US
Mailing Address - Phone:707-263-8383
Mailing Address - Fax:707-263-5019
Practice Address - Street 1:925 BEVINS COURT
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-9754
Practice Address - Country:US
Practice Address - Phone:707-263-8383
Practice Address - Fax:707-263-5019
Is Sole Proprietor?:No
Enumeration Date:2012-01-05
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA52485363AM0700X
NY015421363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03419101Medicaid
NYJ400063101Medicare PIN