Provider Demographics
NPI:1902140874
Name:ZENTZ, MARY LOU (PA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LOU
Last Name:ZENTZ
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 1:4200 SUN'N LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:SEBRING
Mailing Address - State:FL
Mailing Address - Zip Code:33872-1986
Mailing Address - Country:US
Mailing Address - Phone:863-402-3402
Mailing Address - Fax:863-402-3166
Practice Address - Street 1:4200 SUN'N LAKE BLVD
Practice Address - Street 2:
Practice Address - City:SEBRING
Practice Address - State:FL
Practice Address - Zip Code:33872-1986
Practice Address - Country:US
Practice Address - Phone:863-402-3402
Practice Address - Fax:863-402-3166
Is Sole Proprietor?:No
Enumeration Date:2012-11-16
Last Update Date:2013-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 2332363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA 2332OtherPA LICENSE - STATE OF FLORIDA