Provider Demographics
NPI:1295133197
Name:MAZZONI, MICHAEL (PA-C)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MAZZONI
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 1:200 LEESE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-6967
Mailing Address - Country:US
Mailing Address - Phone:210-243-5456
Mailing Address - Fax:
Practice Address - Street 1:200 LEESE DR
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259-6967
Practice Address - Country:US
Practice Address - Phone:210-243-5456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-09
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1123046363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant