Provider Demographics
NPI:1679040331
Name:MERTEN, MCKENNA JO (PA-C)
Entity Type:Individual
Prefix:
First Name:MCKENNA
Middle Name:JO
Last Name:MERTEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MCKENNA
Other - Middle Name:JO
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16811 SOUTHWEST FWY
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77479-4728
Mailing Address - Country:US
Mailing Address - Phone:281-690-4678
Mailing Address - Fax:
Practice Address - Street 1:16811 SOUTHWEST FWY
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77479
Practice Address - Country:US
Practice Address - Phone:281-690-4678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-30
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA12325363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX392047202Medicaid