Provider Demographics
NPI:1083910491
Name:MITCHELL, BYRON ANTONIUS SR (PA-C)
Entity Type:Individual
Prefix:MR
First Name:BYRON
Middle Name:ANTONIUS
Last Name:MITCHELL
Suffix:SR
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3535 SOUTHERN BLVD
Mailing Address - Street 2:TRAUMA DEPARTMENT
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-1221
Mailing Address - Country:US
Mailing Address - Phone:937-395-6010
Mailing Address - Fax:937-522-7873
Practice Address - Street 1:3535 SOUTHERN BLVD
Practice Address - Street 2:TRAUMA DEPARTMENT
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429
Practice Address - Country:US
Practice Address - Phone:937-395-6010
Practice Address - Fax:937-522-7873
Is Sole Proprietor?:No
Enumeration Date:2011-02-02
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50003256363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0085233Medicaid
12331601OtherCAQH
OHH056302Medicare PIN