Provider Demographics
NPI:1801073655
Name:MICKELSEN, TRACY D (CSFA)
Entity type:Individual
Prefix:MR
First Name:TRACY
Middle Name:D
Last Name:MICKELSEN
Suffix:
Gender:M
Credentials:CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3015 E MAGIC VIEW DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-3743
Mailing Address - Country:US
Mailing Address - Phone:208-855-2410
Mailing Address - Fax:208-482-5515
Practice Address - Street 1:3015 E MAGIC VIEW DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-3743
Practice Address - Country:US
Practice Address - Phone:208-855-2410
Practice Address - Fax:208-482-5515
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-23
Last Update Date:2017-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID178692363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical