Basic Information
| Provider Information | |||||||||
| NPI: | 1093715971 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEZZLES | ||||||||
| FirstName: | JENINE | ||||||||
| MiddleName: | BRINKMANN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6101 BLUE LAGOON DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331263168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5615705172 | ||||||||
| FaxNumber: | 7864725770 | ||||||||
| Practice Location | |||||||||
| Address1: | 1314 GUADALUPE ST STE 105 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782075582 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1093715971 | ||||||||
| FaxNumber: | 2106863831 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2005 | ||||||||
| LastUpdateDate: | 10/11/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA 00638 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | PA00638 | 01 | TX | LISCENCE NUMBER | OTHER |