Provider Demographics
NPI:1346589876
Name:PENAREDONDO, MIKAELA A (PA-C)
Entity Type:Individual
Prefix:
First Name:MIKAELA
Middle Name:A
Last Name:PENAREDONDO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MIKAELA
Other - Middle Name:A
Other - Last Name:DIERKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6100 S LOUISE AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-6029
Mailing Address - Country:US
Mailing Address - Phone:605-504-1000
Mailing Address - Fax:
Practice Address - Street 1:6100 S LOUISE AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-6029
Practice Address - Country:US
Practice Address - Phone:605-504-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-04
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1709363AM0700X
MN2069363AM0700X
MN11579363AM0700X, 363A00000X
SD1417363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant