Provider Demographics
NPI:1679198378
Name:MOTICSAK, MIKAELA (NP)
Entity Type:Individual
Prefix:
First Name:MIKAELA
Middle Name:
Last Name:MOTICSAK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46422 KRAMER DR
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48315-5734
Mailing Address - Country:US
Mailing Address - Phone:248-930-2059
Mailing Address - Fax:
Practice Address - Street 1:46422 KRAMER DR
Practice Address - Street 2:
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48315-5734
Practice Address - Country:US
Practice Address - Phone:248-930-2059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-09
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704263948363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner