Provider Demographics
NPI:1386643880
Name:MICKULIK, KELLY S (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:S
Last Name:MICKULIK
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 1:3317 PENN AVE
Mailing Address - Street 2:
Mailing Address - City:READING
Mailing Address - State:PA
Mailing Address - Zip Code:19609-1436
Mailing Address - Country:US
Mailing Address - Phone:610-750-7891
Mailing Address - Fax:610-750-7894
Practice Address - Street 1:3317 PENN AVE
Practice Address - Street 2:
Practice Address - City:READING
Practice Address - State:PA
Practice Address - Zip Code:19609-1436
Practice Address - Country:US
Practice Address - Phone:610-750-7891
Practice Address - Fax:610-750-7894
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA050888363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA243966YEBK - 213827Medicare PIN
PA058666Medicare ID - Type Unspecified
PAP60926Medicare UPIN