Provider Demographics
NPI:1679540587
Name:MENTZER, CARLETON A III (PA-C)
Entity Type:Individual
Prefix:MR
First Name:CARLETON
Middle Name:A
Last Name:MENTZER
Suffix:III
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1818 HENDERSON ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-2619
Mailing Address - Country:US
Mailing Address - Phone:803-758-2600
Mailing Address - Fax:803-253-8896
Practice Address - Street 1:64 BLUFFTON RD
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:SC
Practice Address - Zip Code:29910-7621
Practice Address - Country:US
Practice Address - Phone:843-757-0676
Practice Address - Fax:843-757-0779
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA.200003363A00000X
SC1652363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1380PAMedicaid
LAQ53008Medicare UPIN