Provider Demographics
NPI:1689944779
Name:MIETZ, MICHAEL KEITH (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:KEITH
Last Name:MIETZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 HOBART ST
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-4308
Mailing Address - Country:US
Mailing Address - Phone:315-798-1149
Mailing Address - Fax:315-734-3565
Practice Address - Street 1:120 HOBART ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13501-4308
Practice Address - Country:US
Practice Address - Phone:315-798-1149
Practice Address - Fax:315-734-3565
Is Sole Proprietor?:No
Enumeration Date:2012-01-05
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015421363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03419101Medicaid
NYJ400063101Medicare PIN