Provider Demographics
NPI:1558301150
Name:MICKLE, IRMA (NP)
Entity Type:Individual
Prefix:
First Name:IRMA
Middle Name:
Last Name:MICKLE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:IRMA
Other - Middle Name:
Other - Last Name:RODRIQUEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:9006 N NAVARRO ST STE B
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77904-1566
Mailing Address - Country:US
Mailing Address - Phone:361-485-0500
Mailing Address - Fax:
Practice Address - Street 1:9006 N NAVARRO ST STE B
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77904-1566
Practice Address - Country:US
Practice Address - Phone:361-485-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX249963363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149335504Medicaid
TX8D5585Medicare PIN
P57914Medicare UPIN
P00216559Medicare PIN