Provider Demographics
NPI:1508913443
Name:LOCKE, MINI K (PA-C)
Entity Type:Individual
Prefix:
First Name:MINI
Middle Name:K
Last Name:LOCKE
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 1:1100 SKYLINE DR
Mailing Address - Street 2:
Mailing Address - City:DECORAH
Mailing Address - State:IA
Mailing Address - Zip Code:52101-2514
Mailing Address - Country:US
Mailing Address - Phone:563-382-4016
Mailing Address - Fax:
Practice Address - Street 1:305 MONTGOMERY ST
Practice Address - Street 2:
Practice Address - City:DECORAH
Practice Address - State:IA
Practice Address - Zip Code:52101-2721
Practice Address - Country:US
Practice Address - Phone:563-382-8436
Practice Address - Fax:563-382-5140
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA000756363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical