Provider Demographics
NPI:1700194651
Name:SOLANO, MITZI M (PA-C)
Entity Type:Individual
Prefix:
First Name:MITZI
Middle Name:M
Last Name:SOLANO
Suffix:
Gender:F
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 1:2175 BLAKESLEE BOULEVARD DR W
Mailing Address - Street 2:
Mailing Address - City:LEHIGHTON
Mailing Address - State:PA
Mailing Address - Zip Code:18235-9776
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2175 BLAKESLEE BOULEVARD DR W
Practice Address - Street 2:
Practice Address - City:LEHIGHTON
Practice Address - State:PA
Practice Address - Zip Code:18235-9776
Practice Address - Country:US
Practice Address - Phone:570-386-4171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-14
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
PAMA055657363A00000X
PAOA004019363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003105085AMedicaid
GA202I979720Medicare PIN