Provider Demographics
NPI:1609016336
Name:MIKASOBE, ANTHONY K (BSMT, AMT, ASCP)
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:K
Last Name:MIKASOBE
Suffix:
Gender:M
Credentials:BSMT, AMT, ASCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 22043
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37202-2043
Mailing Address - Country:US
Mailing Address - Phone:615-472-8312
Mailing Address - Fax:615-472-8312
Practice Address - Street 1:9409 WHITTINGHAM DR
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-8460
Practice Address - Country:US
Practice Address - Phone:615-472-8312
Practice Address - Fax:615-472-8312
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-20
Last Update Date:2009-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN22459291U00000X
PR3653291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory