Provider Demographics
NPI:1699702944
Name:MUKAVETZ, MEGAN (PA)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:MUKAVETZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 E MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-1847
Mailing Address - Country:US
Mailing Address - Phone:517-205-7605
Mailing Address - Fax:
Practice Address - Street 1:1100 E MICHIGAN AVE STE 307
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1850
Practice Address - Country:US
Practice Address - Phone:517-205-7605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008959363A00000X
FLPA9103210363A00000X, 363AS0400X
WAPA60948597363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL292128600Medicaid
P00207686OtherRAILROAD MEDICARE
FL292128600Medicaid
FLU4516AMedicare ID - Type Unspecified