Provider Demographics
NPI:1326747726
Name:MIKKELSON, MIKENZIE MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:MIKENZIE
Middle Name:MARIE
Last Name:MIKKELSON
Suffix:
Gender:F
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 1:1635 CAREGIVER CIR
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-8529
Mailing Address - Country:US
Mailing Address - Phone:605-755-6700
Mailing Address - Fax:
Practice Address - Street 1:1635 CAREGIVER CIR
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-8529
Practice Address - Country:US
Practice Address - Phone:605-755-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-24
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant