Provider Demographics
NPI:1275120404
Name:KASS, MITCHELL PRESTON (PA-C)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:PRESTON
Last Name:KASS
Suffix:
Gender:M
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:PO BOX 26666
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:504-923-6770
Mailing Address - Fax:505-923-5354
Practice Address - Street 1:201 CEDAR ST SE STE 7600
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-4921
Practice Address - Country:US
Practice Address - Phone:505-563-2500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-22
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2022-0066363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant