Provider Demographics
NPI:1659383842
Name:MIKISKA, ROBERT W (PA-C)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
Last Name:MIKISKA
Suffix:
Gender:M
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 1:1550 S PIONEER WAY STE 100
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-4637
Mailing Address - Country:US
Mailing Address - Phone:509-793-9790
Mailing Address - Fax:509-764-3255
Practice Address - Street 1:1550 S PIONEER WAY STE 100
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-4637
Practice Address - Country:US
Practice Address - Phone:509-793-9790
Practice Address - Fax:509-764-3255
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003227363A00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8324220Medicaid
MT1659383842Medicaid
WAAB22580Medicare ID - Type Unspecified
WAP33893Medicare UPIN
MT1659383842Medicaid