Provider Demographics
NPI:1033469531
Name:MICKE, THERESA M (PA-C)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:M
Last Name:MICKE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:M
Other - Last Name:JAEGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 399
Mailing Address - Street 2:
Mailing Address - City:BENSON
Mailing Address - State:NC
Mailing Address - Zip Code:27504-0399
Mailing Address - Country:US
Mailing Address - Phone:919-894-2011
Mailing Address - Fax:919-894-7645
Practice Address - Street 1:3333 NC HIGHWAY 242 N
Practice Address - Street 2:
Practice Address - City:BENSON
Practice Address - State:NC
Practice Address - Zip Code:27504-7844
Practice Address - Country:US
Practice Address - Phone:919-894-2011
Practice Address - Fax:919-894-7645
Is Sole Proprietor?:No
Enumeration Date:2012-09-12
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-04279363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant