Provider Demographics
NPI:1376735126
Name:METZGER, MANDY MARIE (PA)
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:MARIE
Last Name:METZGER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 S BUENA VISTA ST
Mailing Address - Street 2:#470
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505-4554
Mailing Address - Country:US
Mailing Address - Phone:818-848-3030
Mailing Address - Fax:818-848-2228
Practice Address - Street 1:191 S BUENA VISTA ST
Practice Address - Street 2:#470
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-4554
Practice Address - Country:US
Practice Address - Phone:818-848-3030
Practice Address - Fax:818-848-2228
Is Sole Proprietor?:No
Enumeration Date:2007-08-15
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA21277363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
HOPA29461Medicare UPIN