Healthcare Provider Details

I. General information

NPI: 1669832887
Provider Name (Legal Business Name): PHILIP M MICKSCH NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2016
Last Update Date: 04/23/2020
Certification Date: 04/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5300 MEMORIAL DR SUITE 303
TWO RIVERS WI
54241-3923
US

IV. Provider business mailing address

5300 MEMORIAL DR SUITE 303
TWO RIVERS WI
54241-3923
US

V. Phone/Fax

Practice location:
  • Phone: 920-793-6550
  • Fax: 920-793-6551
Mailing address:
  • Phone: 920-793-6550
  • Fax: 920-793-6551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number6871-33
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number6871 - 33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: