Provider Demographics
NPI:1477636496
Name:MITCHELL, GREGORY N (PA-C)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:N
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:GREG
Other - Middle Name:N
Other - Last Name:MITCHELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:3400 DATA DR
Mailing Address - Street 2:ATTN CREDENTIALING/PAYER ENROLLMETN
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:401 E HIGHLAND AVE STE 251
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-3800
Practice Address - Country:US
Practice Address - Phone:909-882-4605
Practice Address - Fax:909-475-2680
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18652363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA18652OtherLICENSE
CA0PA186520Medicaid
CAPA18652OtherLICENSE
ZZZ07161ZOtherMEDICARE GROUP PTAN
CA0PA186520Medicaid