Healthcare Provider Details

I. General information

NPI: 1205219680
Provider Name (Legal Business Name): MITCHELL J LIND PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2015
Last Update Date: 08/28/2025
Certification Date: 08/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1630 COMMANCHE AVE
GREEN BAY WI
54313-5753
US

IV. Provider business mailing address

3059 VOYAGER DR
GREEN BAY WI
54311-8303
US

V. Phone/Fax

Practice location:
  • Phone: 920-430-4700
  • Fax: 920-430-4747
Mailing address:
  • Phone: 920-445-7222
  • Fax: 920-445-7229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3610-23
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number3610-23
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: