Provider Demographics
NPI:1508338732
Name:MICKELSON, ERIN LEAH
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:LEAH
Last Name:MICKELSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 BROADMOOR
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-5086
Mailing Address - Country:US
Mailing Address - Phone:928-445-2692
Mailing Address - Fax:
Practice Address - Street 1:1542 MARVIN GARDENS LN
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-5528
Practice Address - Country:US
Practice Address - Phone:928-312-2011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-28
Last Update Date:2018-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ137284207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine