Provider Demographics
NPI:1114194230
Name:MICKELSON, NATHAN JAMES
Entity Type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:JAMES
Last Name:MICKELSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 E 12TH ST APT 1102
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44114-3538
Mailing Address - Country:US
Mailing Address - Phone:701-471-2240
Mailing Address - Fax:
Practice Address - Street 1:5100 W BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43228-1607
Practice Address - Country:US
Practice Address - Phone:614-544-2089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-08
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program