Provider Demographics
NPI:1801676333
Name:MIKULKA, CHARLES ANTHONY III (PA-C)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:ANTHONY
Last Name:MIKULKA
Suffix:III
Gender:M
Credentials:PA-C
Other - Prefix:
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Mailing Address - Street 1:4201 HENRY AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19144-5409
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4201 HENRY AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19144-5409
Practice Address - Country:US
Practice Address - Phone:717-725-1069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-02
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMA065066363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant