Provider Demographics
NPI:1780621151
Name:MIRIKE, ALLISON ANN (PA)
Entity type:Individual
Prefix:
First Name:ALLISON
Middle Name:ANN
Last Name:MIRIKE
Suffix:
Gender:F
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:PO BOX 1962
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76202-1962
Mailing Address - Country:US
Mailing Address - Phone:940-503-3601
Mailing Address - Fax:940-503-3602
Practice Address - Street 1:209 N BONNIE BRAE ST
Practice Address - Street 2:SUITE 304
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76201-3708
Practice Address - Country:US
Practice Address - Phone:940-503-3601
Practice Address - Fax:940-503-3602
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02831363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP90344Medicare UPIN
TX265474YL7AMedicare PIN
TX265474YL7AMedicare PIN