Provider Demographics
NPI:1790910008
Name:MICKIE, JOVANNA ROSE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JOVANNA
Middle Name:ROSE
Last Name:MICKIE
Suffix:
Gender:F
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 1:1001 SAM PERRY
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22408-1822
Mailing Address - Country:US
Mailing Address - Phone:540-741-1167
Mailing Address - Fax:
Practice Address - Street 1:1001 SAM PERRY
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22408-1822
Practice Address - Country:US
Practice Address - Phone:540-741-1167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-16
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002468363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0110002468Medicaid
VA0110002468Medicaid