Provider Demographics
NPI:1912163189
Name:OAKLEY, MICAH (PA-C)
Entity Type:Individual
Prefix:
First Name:MICAH
Middle Name:
Last Name:OAKLEY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3988
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62902-3988
Mailing Address - Country:US
Mailing Address - Phone:618-457-5200
Mailing Address - Fax:
Practice Address - Street 1:405 RUSHING DR
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-3730
Practice Address - Country:US
Practice Address - Phone:618-993-3300
Practice Address - Fax:618-993-0262
Is Sole Proprietor?:No
Enumeration Date:2008-08-06
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003043363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL080077375OtherRAILROAD MEDICARE
IL143870Medicaid
IL036062597Medicaid
IL103788OtherHEALTHLINK
IL10019630OtherBLUE CROSS BLUE SHIELD
IL033308OtherHEALTH ALLIANCE
IL036062597Medicaid
IL214881Medicare Oscar/Certification