Healthcare Provider Details

I. General information

NPI: 1669982039
Provider Name (Legal Business Name): CHRISTIAN MIKESELL AGPCNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2017
Last Update Date: 05/04/2024
Certification Date: 05/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10208 CERNY ST STE 210
RALEIGH NC
27617-7885
US

IV. Provider business mailing address

10208 CERNY ST STE 210
RALEIGH NC
27617-7885
US

V. Phone/Fax

Practice location:
  • Phone: 919-629-1658
  • Fax: 919-484-8218
Mailing address:
  • Phone: 919-629-1658
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number5009947
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: