Provider Demographics
NPI:1093896037
Name:MIKKELSON, MIKAL JOSEPH (PA-C)
Entity Type:Individual
Prefix:
First Name:MIKAL
Middle Name:JOSEPH
Last Name:MIKKELSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 MOULTON AND PARSONS DR
Mailing Address - Street 2:
Mailing Address - City:SAINT JAMES
Mailing Address - State:MN
Mailing Address - Zip Code:56081-5550
Mailing Address - Country:US
Mailing Address - Phone:507-375-3391
Mailing Address - Fax:
Practice Address - Street 1:1101 MOULTON AND PARSONS DR
Practice Address - Street 2:
Practice Address - City:SAINT JAMES
Practice Address - State:MN
Practice Address - Zip Code:56081-5550
Practice Address - Country:US
Practice Address - Phone:507-375-3391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN18412255A2300X
MN10977363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer