Provider Demographics
NPI:1033109392
Name:RAETHKA, MICHAEL ALLAN (PA)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ALLAN
Last Name:RAETHKA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1390 US HIGHWAY 61 STE N1500
Mailing Address - Street 2:
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028-4137
Mailing Address - Country:US
Mailing Address - Phone:636-933-8050
Mailing Address - Fax:
Practice Address - Street 1:1390 US HIGHWAY 61 STE N1500
Practice Address - Street 2:
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-4137
Practice Address - Country:US
Practice Address - Phone:636-933-8050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015021866363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant