Provider Demographics
NPI:1518694223
Name:MYKLEBUST, CASEY (PA)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:MYKLEBUST
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7448 HIGHWAY 281
Mailing Address - Street 2:
Mailing Address - City:CANDO
Mailing Address - State:ND
Mailing Address - Zip Code:58324-9202
Mailing Address - Country:US
Mailing Address - Phone:701-968-4411
Mailing Address - Fax:
Practice Address - Street 1:7448 HIGHWAY 281
Practice Address - Street 2:
Practice Address - City:CANDO
Practice Address - State:ND
Practice Address - Zip Code:58324-9202
Practice Address - Country:US
Practice Address - Phone:701-968-4411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-03
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPAC0959363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant