Provider Demographics
NPI:1144207879
Name:POPPENS, MITCH D (PA-C)
Entity Type:Individual
Prefix:
First Name:MITCH
Middle Name:D
Last Name:POPPENS
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 1:323 SW 10TH ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:SD
Mailing Address - Zip Code:57042-3200
Mailing Address - Country:US
Mailing Address - Phone:605-256-6551
Mailing Address - Fax:605-256-6469
Practice Address - Street 1:323 SW 10TH ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:SD
Practice Address - Zip Code:57042-3200
Practice Address - Country:US
Practice Address - Phone:605-256-6551
Practice Address - Fax:605-256-6469
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0522363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6824594Medicaid
SD6824594Medicaid
SDS41079Medicare ID - Type Unspecified