Provider Demographics
NPI:1689213852
Name:MENTZER, LUKE GRIMES (PA-C)
Entity Type:Individual
Prefix:
First Name:LUKE
Middle Name:GRIMES
Last Name:MENTZER
Suffix:
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 1:4976 ALPHA LN
Mailing Address - Street 2:
Mailing Address - City:HIXSON
Mailing Address - State:TN
Mailing Address - Zip Code:37343-5470
Mailing Address - Country:US
Mailing Address - Phone:423-308-0280
Mailing Address - Fax:423-870-0281
Practice Address - Street 1:7236 BONNY OAKS DR
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-1005
Practice Address - Country:US
Practice Address - Phone:423-892-2319
Practice Address - Fax:423-892-2147
Is Sole Proprietor?:No
Enumeration Date:2020-01-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4191363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant