Provider Demographics
NPI:1578591285
Name:MICKELSON, COURTNEY (PA-C)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:MICKELSON
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 1:3040 W SALT CREEK LN
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60005-1069
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25 E SCHAUMBURG RD
Practice Address - Street 2:SUITE 200
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60194-3550
Practice Address - Country:US
Practice Address - Phone:847-985-9390
Practice Address - Fax:847-985-6986
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-001732363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant