Provider Demographics
NPI:1831882786
Name:SCHENCK, MICAH
Entity type:Individual
Prefix:
First Name:MICAH
Middle Name:
Last Name:SCHENCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2306 VIMINAL CT
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-2223
Mailing Address - Country:US
Mailing Address - Phone:314-809-1512
Mailing Address - Fax:
Practice Address - Street 1:12200 WEBER HILL RD STE 100
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63127-1569
Practice Address - Country:US
Practice Address - Phone:314-698-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-29
Last Update Date:2023-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017035413163W00000X
MO2023023144363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No163W00000XNursing Service ProvidersRegistered Nurse