Provider Demographics
NPI:1194822114
Name:MINTZ, SAMUEL C (PA-C)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:C
Last Name:MINTZ
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 PROSPECT DR
Mailing Address - Street 2:
Mailing Address - City:GLENDIVE
Mailing Address - State:MT
Mailing Address - Zip Code:59330-1943
Mailing Address - Country:US
Mailing Address - Phone:406-345-3306
Mailing Address - Fax:406-345-3358
Practice Address - Street 1:202 PROSPECT DR
Practice Address - Street 2:
Practice Address - City:GLENDIVE
Practice Address - State:MT
Practice Address - Zip Code:59330-1943
Practice Address - Country:US
Practice Address - Phone:406-345-3306
Practice Address - Fax:406-345-3358
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT59363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
R10564Medicare UPIN