Provider Demographics
NPI:1114582590
Name:MIKUT, GREGORY DAVID (ACNP)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:DAVID
Last Name:MIKUT
Suffix:
Gender:M
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12361 W BOLA DR STE 100
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85378-9021
Mailing Address - Country:US
Mailing Address - Phone:602-641-9486
Mailing Address - Fax:480-500-8430
Practice Address - Street 1:12361 W BOLA DR STE 100
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85378-9021
Practice Address - Country:US
Practice Address - Phone:602-641-9486
Practice Address - Fax:480-500-8430
Is Sole Proprietor?:No
Enumeration Date:2019-05-01
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN169267363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care