Healthcare Provider Details

I. General information

NPI: 1689944779
Provider Name (Legal Business Name): MICHAEL KEITH MIETZ PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2012
Last Update Date: 10/31/2024
Certification Date: 10/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 BEVINS COURT
LAKEPORT CA
95453-9754
US

IV. Provider business mailing address

925 BEVINS COURT
LAKEPORT CA
95453-9754
US

V. Phone/Fax

Practice location:
  • Phone: 707-263-8383
  • Fax: 707-263-5019
Mailing address:
  • Phone: 707-263-8383
  • Fax: 707-263-5019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA52485
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number015421
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: