Provider Demographics
NPI:1295969467
Name:MITTENDORF, MAJOR JOSEPH (PA-C)
Entity type:Individual
Prefix:
First Name:MAJOR
Middle Name:JOSEPH
Last Name:MITTENDORF
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 1:15960 HIGHLAND RD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70810-6512
Mailing Address - Country:US
Mailing Address - Phone:225-752-2276
Mailing Address - Fax:
Practice Address - Street 1:12091 BRICKSOME AVE
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-2699
Practice Address - Country:US
Practice Address - Phone:225-756-2673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-04
Last Update Date:2009-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA10250363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant