Provider Demographics
NPI:1073917209
Name:MICKEY, ADAM DEAN (PA)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:DEAN
Last Name:MICKEY
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 1:2242 W ROOSEVELT BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28110-3071
Mailing Address - Country:US
Mailing Address - Phone:704-220-1904
Mailing Address - Fax:704-776-9495
Practice Address - Street 1:2242 W ROOSEVELT BLVD STE A
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28110
Practice Address - Country:US
Practice Address - Phone:704-220-1904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-17
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9108348363AS0400X
NC0010-07049363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003156207AMedicaid
FL013627200Medicaid
GA003156207AMedicaid
FLP01486938Medicare PIN