Basic Information
| Provider Information | |||||||||
| NPI: | 1073917209 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MICKEY | ||||||||
| FirstName: | ADAM | ||||||||
| MiddleName: | DEAN | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2242 W ROOSEVELT BLVD STE A | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281103071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042201904 | ||||||||
| FaxNumber: | 7047769495 | ||||||||
| Practice Location | |||||||||
| Address1: | 2242 W ROOSEVELT BLVD STE A | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042201904 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2014 | ||||||||
| LastUpdateDate: | 10/30/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | PA9108348 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AM0700X | 0010-07049 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 003156207A | 05 | GA | MEDICAID | 013627200 | 05 | FL | MEDICAID |