Provider Demographics
NPI:1669734315
Name:MIKA, MARCIN T (APRN, MSN, PMHNP-BC)
Entity type:Individual
Prefix:MR
First Name:MARCIN
Middle Name:T
Last Name:MIKA
Suffix:
Gender:M
Credentials:APRN, MSN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1024 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-1745
Mailing Address - Country:US
Mailing Address - Phone:630-262-2640
Mailing Address - Fax:630-262-2645
Practice Address - Street 1:1024 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-1745
Practice Address - Country:US
Practice Address - Phone:630-262-2640
Practice Address - Fax:630-262-2645
Is Sole Proprietor?:No
Enumeration Date:2012-06-08
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAG138288363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health