Basic Information
| Provider Information | |||||||||
| NPI: | 1861591257 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIKESCH | ||||||||
| FirstName: | ROXANNE | ||||||||
| MiddleName: | |||||||||
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| Credential: | APN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9007 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658089007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178753000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3800 S NATIONAL AVE STE 400 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658075272 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178753210 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2006 | ||||||||
| LastUpdateDate: | 09/10/2013 | ||||||||
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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 | 163W00000X | 083182 | MO | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 83182 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 083182 | 01 | MO | STATE LICENSE | OTHER | 1861591257 | 05 | MO | MEDICAID |