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General NPI Number Information
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NPI Number | 1558565929
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Entity Type | Individual
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Provider Name | MR. KENNETH ROY MAZER
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Gender | Male
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Dates
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Enumeration Date | 06/12/2007
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Last Update Date | 09/11/2024
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Provider Practice Location Address
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Address Line | 6847 N CHESTNUT ST
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City | RAVENNA
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State | OH
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Zip | 44266-3929
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Country | US
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Telephone | 330-493-4443
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Fax |
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Provider Business Mailing Address
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Address Line | 10930 CLAY ST
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City | MONTVILLE
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State | OH
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Zip | 44064-9702
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1710I1002X
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Taxonomy Name | Independent Duty Corpsman
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 50.003940RX
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License Number State | OH
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