Provider Demographics
NPI:1801362173
Name:MENZA, MIKE (MMS PA-C)
Entity Type:Individual
Prefix:
First Name:MIKE
Middle Name:
Last Name:MENZA
Suffix:
Gender:M
Credentials:MMS PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 MIDDLE RIVER DR APT 117
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33304-3505
Mailing Address - Country:US
Mailing Address - Phone:908-391-5727
Mailing Address - Fax:
Practice Address - Street 1:8300 N LAMAR BLVD STE 200A
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78753-5976
Practice Address - Country:US
Practice Address - Phone:512-695-3833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-15
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9111687363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant