Provider Demographics
NPI:1629292669
Name:MICKLEBURGH, ANNE (PAC)
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:
Last Name:MICKLEBURGH
Suffix:
Gender:F
Credentials:PAC
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 848476
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-8476
Mailing Address - Country:US
Mailing Address - Phone:254-202-4655
Mailing Address - Fax:254-202-4697
Practice Address - Street 1:2304 MARKETPLACE DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76711-2467
Practice Address - Country:US
Practice Address - Phone:254-202-7300
Practice Address - Fax:254-202-7350
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02063363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXS44557Medicare UPIN
TX8D3219Medicare ID - Type UnspecifiedMEDICARE INDIVIDUAL
TX00U73UMedicare ID - Type UnspecifiedMEDICARE GROUP