Healthcare Provider Details

I. General information

NPI: 1467531392
Provider Name (Legal Business Name): CLINTON AARON MITCHELL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 11/30/2021
Certification Date: 04/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 WILSON TER SUITE 200
GLENDALE CA
91206-4071
US

IV. Provider business mailing address

PHR GROUP PE UNIT 3RD FLOOR 393 E WALNT STREET
PASADENA CA
91188-0001
US

V. Phone/Fax

Practice location:
  • Phone: 818-246-8974
  • Fax: 818-246-7673
Mailing address:
  • Phone: 626-405-7914
  • Fax: 877-514-0903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA 18069
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: