Provider Demographics
NPI:1790772325
Name:SIKES, MICHAEL RANDOLPH (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:RANDOLPH
Last Name:SIKES
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 1:700 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:STANLEY
Mailing Address - State:NC
Mailing Address - Zip Code:28164-1438
Mailing Address - Country:US
Mailing Address - Phone:704-263-8945
Mailing Address - Fax:704-263-2591
Practice Address - Street 1:700 N MAIN ST
Practice Address - Street 2:
Practice Address - City:STANLEY
Practice Address - State:NC
Practice Address - Zip Code:28164-1438
Practice Address - Country:US
Practice Address - Phone:704-263-8945
Practice Address - Fax:704-263-2591
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC100166363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCR77869Medicare UPIN
NC2747295Medicare PIN