Provider Demographics
NPI:1457004012
Name:VARTANIAN, MIKEL P
Entity Type:Individual
Prefix:
First Name:MIKEL
Middle Name:P
Last Name:VARTANIAN
Suffix:
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 1:10549 REDLAND ST. N.
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36695-3832
Mailing Address - Country:US
Mailing Address - Phone:310-804-7094
Mailing Address - Fax:
Practice Address - Street 1:8501 TANNER WILLIAMS RD
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36608-8322
Practice Address - Country:US
Practice Address - Phone:251-441-6401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-02
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2034363A00000X
FLPA9115801363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant