Provider Demographics
NPI:1568034619
Name:MITCHELL, IAN JOSEPH
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:JOSEPH
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 1:833 CHESTNUT ST STE 520
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4430
Mailing Address - Country:US
Mailing Address - Phone:267-606-4478
Mailing Address - Fax:267-339-3761
Practice Address - Street 1:2500 ENGLISH CREEK AVE STE 1300
Practice Address - Street 2:
Practice Address - City:EGG HARBOR TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:08234-5598
Practice Address - Country:US
Practice Address - Phone:609-677-6060
Practice Address - Fax:609-677-7000
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-16
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AS0400X
NJ25MP00663000363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty