Provider Demographics
NPI:1477673804
Name:MICKELSON, STEVEN DON (PA)
Entity type:Individual
Prefix:MR
First Name:STEVEN
Middle Name:DON
Last Name:MICKELSON
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7800 SHOAL CREEK BLVD
Mailing Address - Street 2:STE 205-N
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78757-1098
Mailing Address - Country:US
Mailing Address - Phone:512-206-4300
Mailing Address - Fax:512-206-4376
Practice Address - Street 1:651 1ST ST W STE L
Practice Address - Street 2:
Practice Address - City:SONOMA
Practice Address - State:CA
Practice Address - Zip Code:95476-7046
Practice Address - Country:US
Practice Address - Phone:415-927-0666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2025-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05217363AM0700X
CAPA65992363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8J8379Medicare PIN