Provider Demographics
NPI:1548209463
Name:MIKSA, PAULA RENEE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:PAULA
Middle Name:RENEE
Last Name:MIKSA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:PAULA
Other - Middle Name:RENEE
Other - Last Name:DEMARO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:101 W 27TH ST
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358-3014
Mailing Address - Country:US
Mailing Address - Phone:910-739-0770
Mailing Address - Fax:
Practice Address - Street 1:598 JOHN DEERE DRIVE
Practice Address - Street 2:
Practice Address - City:MAYNARDVILLE
Practice Address - State:TN
Practice Address - Zip Code:37807
Practice Address - Country:US
Practice Address - Phone:865-992-6060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003964363AM0700X
TN1271363A00000X
NC0010-05096363A00000X
SCPA2079363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA229393905OtherCHAMPUS
GA617410018AMedicaid
AL009936047Medicaid
TN150877Medicaid
GA97WCHKNMedicare ID - Type Unspecified
GA229393905OtherCHAMPUS
TN150877Medicaid