Provider Demographics
NPI:1033954029
Name:GANZ, MORDECAI (PA-C)
Entity type:Individual
Prefix:
First Name:MORDECAI
Middle Name:
Last Name:GANZ
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1334 CAFFREY AVE APT 2J
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-5126
Mailing Address - Country:US
Mailing Address - Phone:848-525-3911
Mailing Address - Fax:
Practice Address - Street 1:1334 CAFFREY AVE APT 2J
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-5126
Practice Address - Country:US
Practice Address - Phone:848-525-3911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-01
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant