Provider Demographics
NPI:1306867684
Name:MICIKAS, ANNE MARIE (CRNA)
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:MARIE
Last Name:MICIKAS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:575 N RIVER ST
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18764-0999
Mailing Address - Country:US
Mailing Address - Phone:570-829-8111
Mailing Address - Fax:
Practice Address - Street 1:68 S SERVICE RD
Practice Address - Street 2:SUITE 350
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-2354
Practice Address - Country:US
Practice Address - Phone:516-945-3115
Practice Address - Fax:516-945-3131
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2011-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN198985L367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA015078Medicare ID - Type Unspecified
PAS61724Medicare UPIN