Provider Demographics
NPI:1710465430
Name:METZGER, MITCHELL KEITH (CAA)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:KEITH
Last Name:METZGER
Suffix:
Gender:M
Credentials:CAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 KIRKWOOD GLEN CIR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-3245
Mailing Address - Country:US
Mailing Address - Phone:502-235-3091
Mailing Address - Fax:
Practice Address - Street 1:1850 STATE ST
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-4990
Practice Address - Country:US
Practice Address - Phone:812-944-7701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-03
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN75000033A367H00000X
TX367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant