Provider Demographics
NPI:1467448043
Name:MICKELSON, JOSEPH EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:EDWARD
Last Name:MICKELSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6500 E 2ND ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82609-4338
Mailing Address - Country:US
Mailing Address - Phone:307-577-5100
Mailing Address - Fax:307-234-1201
Practice Address - Street 1:6500 E 2ND ST
Practice Address - Street 2:SUITE 200
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82609-4338
Practice Address - Country:US
Practice Address - Phone:307-577-5100
Practice Address - Fax:307-234-1201
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY5638A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY315272OtherBC/BS
G47727Medicare UPIN
WYP00325779Medicare PIN
WYW20630Medicare PIN