Provider Demographics
NPI:1356678270
Name:MICKELSON, GORDON MAX III
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:MAX
Last Name:MICKELSON
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3508 WHITE MOUNTAIN BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82901-6842
Mailing Address - Country:US
Mailing Address - Phone:307-389-9169
Mailing Address - Fax:
Practice Address - Street 1:3508 WHITE MOUNTAIN BLVD
Practice Address - Street 2:
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-6842
Practice Address - Country:US
Practice Address - Phone:307-389-9169
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-13
Last Update Date:2009-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator