Provider Demographics
NPI:1669832887
Name:MICKSCH, PHILIP M (NP)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:M
Last Name:MICKSCH
Suffix:
Gender:M
Credentials:NP
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Other - Credentials:
Mailing Address - Street 1:5300 MEMORIAL DR
Mailing Address - Street 2:SUITE 303
Mailing Address - City:TWO RIVERS
Mailing Address - State:WI
Mailing Address - Zip Code:54241-3923
Mailing Address - Country:US
Mailing Address - Phone:920-793-6550
Mailing Address - Fax:920-793-6551
Practice Address - Street 1:5300 MEMORIAL DR
Practice Address - Street 2:SUITE 303
Practice Address - City:TWO RIVERS
Practice Address - State:WI
Practice Address - Zip Code:54241-3923
Practice Address - Country:US
Practice Address - Phone:920-793-6550
Practice Address - Fax:920-793-6551
Is Sole Proprietor?:No
Enumeration Date:2016-03-01
Last Update Date:2020-04-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WI6871 - 33363LF0000X
WI6871-33363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily