MEDICARE: KRISTIN LEIGH MIKKELSEN PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	0698	SD
2	363AM0700X	Medical Physician Assistant	00097471	CO
3	363A00000X	Physician Assistant	TC371	KY
4	363A00000X	Physician Assistant	10003850A	IN
5	363A00000X	Physician Assistant	00097471	CO
6	363A00000X	Physician Assistant	363AM0700X	OH
7	363A00000X	Physician Assistant	1448-023	WI
8	363A00000X	Physician Assistant
9	363AM0700X	Medical Physician Assistant	50.003856	OH

General Provider Information

NPI Number	:	1750614608
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTIN LEIGH MIKKELSEN PA-C

Provider Business Mailing Address
First Line	:	701 NE BRIDGE CREEK XING
Second Line	:
City	:	GRIMES
State	:	IA
Zip	:	50111-4841
Country	:	US
Telephone Number	:	501-454-9413
Fax Number	:

Provider Business Practice Location Address
First Line	:	1625 FOXTRAIL DR
Second Line	:
City	:	LOVELAND
State	:	CO
Zip	:	80538-9088
Country	:	US
Telephone Number	:	970-500-2244
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/10/2009
Last Update Date	:	01/27/2026

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