Provider Demographics
NPI:1801300330
Name:MIKELONIS, ALEJANDRO (PA-C)
Entity type:Individual
Prefix:
First Name:ALEJANDRO
Middle Name:
Last Name:MIKELONIS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:ALEX
Other - Middle Name:
Other - Last Name:MIKELONIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:574-237-6069
Practice Address - Street 1:610 N MICHIGAN ST STE 306
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1079
Practice Address - Country:US
Practice Address - Phone:574-647-6500
Practice Address - Fax:574-647-6518
Is Sole Proprietor?:No
Enumeration Date:2017-11-20
Last Update Date:2017-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10002386A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300008855Medicaid
IN236040257OtherMEDICARE PTAN
INM59677010OtherMEDICARE PTAN