Provider Demographics
NPI:1851314561
Name:MIELKE, ADAM C (PA-C)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:C
Last Name:MIELKE
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 1:1818 N MEADE ST
Mailing Address - Street 2:SUITE N347
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-3454
Mailing Address - Country:US
Mailing Address - Phone:920-831-6135
Mailing Address - Fax:920-225-1429
Practice Address - Street 1:1818 N MEADE ST
Practice Address - Street 2:SUITE N347
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-3454
Practice Address - Country:US
Practice Address - Phone:920-831-6135
Practice Address - Fax:920-225-1429
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1999363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIQ71480Medicare UPIN
WI0003Medicare PIN