Provider Demographics
NPI:1457466963
Name:MITZEL, SAMUEL JOHN (CRNA)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:JOHN
Last Name:MITZEL
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2907 70TH AVE
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-8969
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3333 S WADSWORTH BLVD UNIT D100
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80227-5117
Practice Address - Country:US
Practice Address - Phone:303-205-1090
Practice Address - Fax:303-205-5534
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2013-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 168226 5367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN246925000Medicaid
MN430005723Medicare PIN