Basic Information
| Provider Information | |||||||||
| NPI: | 1033469531 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MICKE | ||||||||
| FirstName: | THERESA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JAEGER | ||||||||
| OtherFirstName: | THERESA | ||||||||
| OtherMiddleName: | M | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 399 | ||||||||
| Address2: | |||||||||
| City: | BENSON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275040399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198942011 | ||||||||
| FaxNumber: | 9198947645 | ||||||||
| Practice Location | |||||||||
| Address1: | 3333 NC HIGHWAY 242 N | ||||||||
| Address2: | |||||||||
| City: | BENSON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275047844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198942011 | ||||||||
| FaxNumber: | 9198947645 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2012 | ||||||||
| LastUpdateDate: | 06/18/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0010-04279 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.