Provider Demographics
NPI:1457014516
Name:MITCHELL, MATTHEW JAMES
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JAMES
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9920 SWAN CREEK RD
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:MI
Mailing Address - Zip Code:48166-9301
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2213 CHERRY ST
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43608-2603
Practice Address - Country:US
Practice Address - Phone:419-251-3232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-15
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.428801163W00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse