Provider Demographics
NPI:1164194593
Name:HALL, MITCHELL GLEN (PAC)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:GLEN
Last Name:HALL
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6600 E 2ND ST STE A
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82609-4348
Mailing Address - Country:US
Mailing Address - Phone:307-333-4363
Mailing Address - Fax:
Practice Address - Street 1:6600 E 2ND ST STE A
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82609-4348
Practice Address - Country:US
Practice Address - Phone:307-333-4363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-04
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPT956363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical