Provider Demographics
NPI:1922431576
Name:MINTZ, EDITH (PA)
Entity Type:Individual
Prefix:
First Name:EDITH
Middle Name:
Last Name:MINTZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 936857
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-6857
Mailing Address - Country:US
Mailing Address - Phone:910-662-9500
Mailing Address - Fax:910-662-9501
Practice Address - Street 1:1415 PHYSICIANS DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7338
Practice Address - Country:US
Practice Address - Phone:910-662-9500
Practice Address - Fax:910-662-9501
Is Sole Proprietor?:No
Enumeration Date:2013-08-19
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC0010-04295363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1922431576Medicaid
NCNCI180BMedicare PIN