Provider Demographics
NPI:1013531458
Name:MICK, MICHAELYN (LRT)
Entity Type:Individual
Prefix:
First Name:MICHAELYN
Middle Name:
Last Name:MICK
Suffix:
Gender:F
Credentials:LRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 N STARK ST
Mailing Address - Street 2:
Mailing Address - City:BENNINGTON
Mailing Address - State:KS
Mailing Address - Zip Code:67422-9429
Mailing Address - Country:US
Mailing Address - Phone:785-416-0033
Mailing Address - Fax:
Practice Address - Street 1:2265 S 9TH ST
Practice Address - Street 2:
Practice Address - City:SALINA
Practice Address - State:KS
Practice Address - Zip Code:67401-7308
Practice Address - Country:US
Practice Address - Phone:785-452-6002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-02
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS22059232085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS2205923OtherARRT