Healthcare Provider Details

I. General information

NPI: 1396611877
Provider Name (Legal Business Name): MITCHELL ALEXANDER WARD PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2025
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

717 E VENICE AVE
VENICE FL
34285-7038
US

IV. Provider business mailing address

717 E VENICE AVE
VENICE FL
34285-7038
US

V. Phone/Fax

Practice location:
  • Phone: 717-810-7480
  • Fax:
Mailing address:
  • Phone: 717-810-7480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: