Provider Demographics
NPI:1093937906
Name:MIERISCH, HENRY (PA)
Entity Type:Individual
Prefix:MR
First Name:HENRY
Middle Name:
Last Name:MIERISCH
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 1:2525 NW 54TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33142-2947
Mailing Address - Country:US
Mailing Address - Phone:305-633-9090
Mailing Address - Fax:305-633-9383
Practice Address - Street 1:2525 NW 54TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33142-2947
Practice Address - Country:US
Practice Address - Phone:305-633-9090
Practice Address - Fax:305-633-9383
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9100034363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant