Basic Information
| Provider Information | |||||||||
| NPI: | 1558773028 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MICKENS | ||||||||
| FirstName: | BOBBY | ||||||||
| MiddleName: | JEAN | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3003 N CENTRAL AVE STE 1600 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850122908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6023233344 | ||||||||
| FaxNumber: | 6023233496 | ||||||||
| Practice Location | |||||||||
| Address1: | 303 E BASELINE RD | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850426530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 0224372776 | ||||||||
| FaxNumber: | 6022764427 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2014 | ||||||||
| LastUpdateDate: | 07/07/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 2006020259 | MO | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LW0102X | 241811 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
No ID Information.