Provider Demographics
NPI:1881782332
Name:MICKELSON, KURT PHILLIP
Entity type:Individual
Prefix:
First Name:KURT
Middle Name:PHILLIP
Last Name:MICKELSON
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 1:155 LARGS CT # 2-207
Mailing Address - Street 2:
Mailing Address - City:DUNEDIN
Mailing Address - State:FL
Mailing Address - Zip Code:34698-8387
Mailing Address - Country:US
Mailing Address - Phone:808-375-9232
Mailing Address - Fax:
Practice Address - Street 1:15100 RESCUE WAY
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33762
Practice Address - Country:US
Practice Address - Phone:727-535-1437
Practice Address - Fax:727-535-4190
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other