Provider Demographics
NPI:1508407966
Name:MIKOLAS, RUSTY (ATP)
Entity Type:Individual
Prefix:
First Name:RUSTY
Middle Name:
Last Name:MIKOLAS
Suffix:
Gender:M
Credentials:ATP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5959 SHALLOWFORD RD STE 443
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-2245
Mailing Address - Country:US
Mailing Address - Phone:423-756-2268
Mailing Address - Fax:423-362-5413
Practice Address - Street 1:9494 KIRBY DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77054-2521
Practice Address - Country:US
Practice Address - Phone:713-791-9080
Practice Address - Fax:713-791-9084
Is Sole Proprietor?:No
Enumeration Date:2019-10-07
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247000000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Health Information