Provider Demographics
NPI:1073741641
Name:MICKSCHL, DARA J (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:DARA
Middle Name:J
Last Name:MICKSCHL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:DARA
Other - Middle Name:J
Other - Last Name:HORNIK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-7400
Mailing Address - Fax:414-805-7388
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-3666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-23
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2410363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1073741641Medicaid