Healthcare Provider Details

I. General information

NPI: 1679722714
Provider Name (Legal Business Name): ROBERT MICKLAS PA-C, MMS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2008
Last Update Date: 09/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3399 NW 72ND AVE (SUITE 101)
MIAMI FL
33122-1349
US

IV. Provider business mailing address

3399 NW 72ND AVE (SUITE 101)
MIAMI FL
33122-1349
US

V. Phone/Fax

Practice location:
  • Phone: 305-599-9933
  • Fax:
Mailing address:
  • Phone: 305-599-9933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA 9101675
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: