Provider Demographics
NPI:1457879140
Name:STUART, MYKAELA DENISE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MYKAELA
Middle Name:DENISE
Last Name:STUART
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MYKAELA
Other - Middle Name:DENISE
Other - Last Name:WETHERINGTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:994 MARQUETTE LOOP
Mailing Address - Street 2:
Mailing Address - City:NORTH POLE
Mailing Address - State:AK
Mailing Address - Zip Code:99705-7895
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1001 NOBLE ST STE 1
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4991
Practice Address - Country:US
Practice Address - Phone:907-459-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-01
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK138684363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical