Provider Demographics
NPI:1578714317
Name:MENTINK, PAMELA A (PA)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:A
Last Name:MENTINK
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:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:920-282-2530
Mailing Address - Fax:
Practice Address - Street 1:3400 UNION AVE
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-8426
Practice Address - Country:US
Practice Address - Phone:920-282-2530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-09
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2354-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100000703Medicaid
WI2354-23OtherWI LICENSE