Provider Demographics
NPI:1861626632
Name:MIKITCHUK, MARINA (PA)
Entity Type:Individual
Prefix:
First Name:MARINA
Middle Name:
Last Name:MIKITCHUK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 NW 13TH ST STE 201
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33486-2269
Mailing Address - Country:US
Mailing Address - Phone:561-955-6663
Mailing Address - Fax:
Practice Address - Street 1:10 E PALMETTO PARK RD
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33432-4864
Practice Address - Country:US
Practice Address - Phone:718-996-1448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-08
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013207363AS0400X
FL9109430363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical