Provider Demographics
NPI:1245014620
Name:BRUTICO, MIKAELA (PA-C)
Entity type:Individual
Prefix:
First Name:MIKAELA
Middle Name:
Last Name:BRUTICO
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-207-4054
Mailing Address - Fax:570-201-4057
Practice Address - Street 1:3 W OLIVE ST
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18508-2572
Practice Address - Country:US
Practice Address - Phone:570-207-4054
Practice Address - Fax:570-207-4057
Is Sole Proprietor?:No
Enumeration Date:2023-08-24
Last Update Date:2025-05-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMA064835363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant