Provider Demographics
NPI:1922480896
Name:MIZUTA, MICHAEL T (CRNA)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:T
Last Name:MIZUTA
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 551420
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33355-1420
Mailing Address - Country:US
Mailing Address - Phone:800-243-3839
Mailing Address - Fax:855-851-4405
Practice Address - Street 1:4725 N FEDERAL HIGHWAY
Practice Address - Street 2:AMERICAN ANESTHESIOLOGY SERVICES OF FLORIDA, INC.
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-4603
Practice Address - Country:US
Practice Address - Phone:954-493-5005
Practice Address - Fax:954-938-0957
Is Sole Proprietor?:No
Enumeration Date:2015-06-26
Last Update Date:2017-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA720891163W00000X
FLARNP9441386367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018674700Medicaid